MEDICARE: JACKIE LINH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	OA002763	PA

General Provider Information

NPI Number	:	1194002063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE LINH PA-C

Provider Business Mailing Address
First Line	:	5903 N LEITHGOW ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 CHICHESTER AVE
Second Line	:
City	:	UPPER CHICHESTER
State	:	PA
Zip	:	19061-3138
Country	:	US
Telephone Number	:	610-494-4422
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2011
Last Update Date	:	11/07/2011

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