1770733503 NPI number — DR. JACKLYN LEE CHANDLER PH.D.

Table of content: DR. JACKLYN LEE CHANDLER PH.D. (NPI 1770733503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770733503 NPI number — DR. JACKLYN LEE CHANDLER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANDLER
Provider First Name:
JACKLYN
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770733503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 SYDNEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94507-2673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-477-5544
Provider Business Mailing Address Fax Number:
925-944-0151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 SYDNEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94507-2673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-477-5544
Provider Business Practice Location Address Fax Number:
925-944-0151
Provider Enumeration Date:
09/29/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSB 32545 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)