Basic Information
| Provider Information | |||||||||
| NPI: | 1265485684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YU | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 544 N GLENDALE AVE STE B | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912063311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7472123441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | G55744 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207QG0300X | G55744 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | G55744 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | G55744 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G557440 | 05 | CA | MEDICAID |