=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740267715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE SUSANNA CHAN D.O./OSTEOPATH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2005
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 LARKSPUR LANDING CIRCLE #255
-----------------------------------------------------
City | LARKSPUR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-945-3213
-----------------------------------------------------
Fax | 415-329-5080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 LARKSPUR LANDING CIR. #255
-----------------------------------------------------
City | LARKSPUR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-945-3213
-----------------------------------------------------
Fax | 415-329-5080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20A10041
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------