Provider Demographics
NPI:1437330123
Name:DR. JACLYN PHAN & ASSOCIATES
Entity type:Organization
Organization Name:DR. JACLYN PHAN & ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-485-6812
Mailing Address - Street 1:1912 201ST PL SE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8570
Mailing Address - Country:US
Mailing Address - Phone:425-485-6812
Mailing Address - Fax:425-485-6813
Practice Address - Street 1:1912 201ST PL SE
Practice Address - Street 2:SUITE 204
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-8570
Practice Address - Country:US
Practice Address - Phone:425-485-6812
Practice Address - Fax:425-485-6813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3357261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2033652Medicaid