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General NPI Number Information
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NPI Number | 1306399563
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Entity Type | Organization
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Legal Business Name | RAVEN ACUPUNCTURE CLINIC, INC.
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Dates
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Enumeration Date | 07/24/2016
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Last Update Date | 08/24/2016
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Provider Practice Location Address
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Address Line | 1961 PRUNERIDGE AVE SUITE B1
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City | SANTA CLARA
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State | CA
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Zip | 95050-6575
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Country | US
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Telephone | 408-758-2881
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Fax | 855-781-8279
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Provider Business Mailing Address
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Address Line | 1961 PRUNERIDGE AVE SUITE B1
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City | SANTA CLARA
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State | CA
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Zip | 95050-6575
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Country | US
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Telephone | 408-758-2881
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Fax | 855-781-8279
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOCELYN CHIE JACKSON
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Credential | L.AC.
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Telephone | 408-758-2881
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 16969
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License Number State | CA
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