Healthcare Provider Details

I. General information

NPI: 1982732236
Provider Name (Legal Business Name): JACQUELYN DIANE SAMMONS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 E CANYON RIM RD STE 105B
ANAHEIM CA
92807-4313
US

IV. Provider business mailing address

6200 E CANYON RIM RD STE 105B
ANAHEIM CA
92807-4313
US

V. Phone/Fax

Practice location:
  • Phone: 714-900-3091
  • Fax: 714-386-5147
Mailing address:
  • Phone: 714-900-3091
  • Fax: 714-386-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A9246
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number9246
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number20A9246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: