Basic Information
| Provider Information | |||||||||
| NPI: | 1760486534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2800 L ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546850 | ||||||||
| FaxNumber: | 9164546852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 33283 | WA | N | Other Service Providers | Legal Medicine | 2084N0400X | G88236 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1101211 | 05 | WA | MEDICAID |