Provider Demographics
NPI:1366798027
Name:TRAN, JACQUELYN (MS, PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:TRAN
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Gender:F
Credentials:MS, PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 S SEPULVEDA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6876
Mailing Address - Country:US
Mailing Address - Phone:310-546-1188
Mailing Address - Fax:310-546-1188
Practice Address - Street 1:400 S SEPULVEDA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6876
Practice Address - Country:US
Practice Address - Phone:310-546-1188
Practice Address - Fax:310-546-1189
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA53139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant