Provider Demographics
NPI:1427651520
Name:ANG, JACKLYN WHITNEY
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:WHITNEY
Last Name:ANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 4TH ST APT 301C
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2271
Mailing Address - Country:US
Mailing Address - Phone:909-524-7791
Mailing Address - Fax:
Practice Address - Street 1:760 HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-1235
Practice Address - Country:US
Practice Address - Phone:415-836-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42939390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program