Provider Demographics
NPI:1699383570
Name:CHAN, JONATHAN (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 DESERT BLOOM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-8872
Mailing Address - Country:US
Mailing Address - Phone:951-392-1320
Mailing Address - Fax:
Practice Address - Street 1:14221 EUCLID ST STE F
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4991
Practice Address - Country:US
Practice Address - Phone:714-891-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist