Provider Demographics
NPI:1447544333
Name:CHAN, JACKYLN WAI-SHAN (MD)
Entity type:Individual
Prefix:
First Name:JACKYLN
Middle Name:WAI-SHAN
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 E VALLEY BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3197
Mailing Address - Country:US
Mailing Address - Phone:909-594-3382
Mailing Address - Fax:
Practice Address - Street 1:2707 E VALLEY BLVD STE 215
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3197
Practice Address - Country:US
Practice Address - Phone:909-594-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130711208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty