MEDICARE: JACKY CHEN M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	294629	NY

General Provider Information

NPI Number	:	1538541305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKY CHEN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 627
Second Line	:
City	:	CORTLAND
State	:	NY
Zip	:	13045-0627
Country	:	US
Telephone Number	:	607-758-8019
Fax Number	:	607-758-8210

Provider Business Practice Location Address
First Line	:	4077 WEST RD
Second Line	:
City	:	CORTLAND
State	:	NY
Zip	:	13045-1637
Country	:	US
Telephone Number	:	607-753-9977
Fax Number	:	607-218-6276

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

Provider Enumeration Date	:	06/29/2015
Last Update Date	:	03/04/2021

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