Provider Demographics
NPI:1023507316
Name:CHAN, JACLYN (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 AMHERST AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3647
Mailing Address - Country:US
Mailing Address - Phone:310-597-9854
Mailing Address - Fax:
Practice Address - Street 1:20501 VENTURA BLVD STE 380
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-6432
Practice Address - Country:US
Practice Address - Phone:818-343-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2910812251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty