MEDICARE: MISS JACLYNN J DO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A78520	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366439051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JACLYNN J DO M.D.

Provider Business Mailing Address
First Line	:	10141 WESTMINSTER AVE
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-4790
Country	:	US
Telephone Number	:	714-467-4321
Fax Number	:	714-467-4311

Provider Business Practice Location Address
First Line	:	10141 WESTMINSTER AVE
Second Line	:	SUITE E
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-4788
Country	:	US
Telephone Number	:	714-467-4321
Fax Number	:	714-467-4311

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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