Provider Demographics
NPI:1902447402
Name:JIANG, AMY (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JIANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4017
Mailing Address - Country:US
Mailing Address - Phone:714-206-0335
Mailing Address - Fax:
Practice Address - Street 1:215 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3528
Practice Address - Country:US
Practice Address - Phone:773-906-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17890171100000X
IL198001481171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist