Healthcare Provider Details

I. General information

NPI: 1104889617
Provider Name (Legal Business Name): JAKLYN RAE MCCLENDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W LA PALMA AVE AMMC - DEPT. OF PATHOLOGY
ANAHEIM CA
92801-2804
US

IV. Provider business mailing address

1111 W LA PALMA AVE DEPT. OF PATHOLOGY
ANAHEIM CA
92801-2804
US

V. Phone/Fax

Practice location:
  • Phone: 714-999-6075
  • Fax: 714-999-3822
Mailing address:
  • Phone: 714-999-6075
  • Fax: 714-999-3822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberG50440
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG50440
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: