Basic Information
| Provider Information | |||||||||
| NPI: | 1982123287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HSU | ||||||||
| FirstName: | JACKSON | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 S EREMLAND DR | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269661577 | ||||||||
| FaxNumber: | 6263314529 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 S EREMLAND DR | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269661577 | ||||||||
| FaxNumber: | 6263314529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2017 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.