Provider Demographics
NPI:1699917021
Name:CHANG, JACK (LAC MS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:LAC MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 SOUTH B STREET
Mailing Address - Street 2:UNIT 221
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:408-823-8659
Mailing Address - Fax:
Practice Address - Street 1:517 SOUTH B STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:408-823-8659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12856171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist