Healthcare Provider Details

I. General information

NPI: 1811422801
Provider Name (Legal Business Name): JACQUELINE MCKESEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 LANDIS AVE STE 300
CHULA VISTA CA
91910-2650
US

IV. Provider business mailing address

256 LANDIS AVE STE 300
CHULA VISTA CA
91910-2650
US

V. Phone/Fax

Practice location:
  • Phone: 619-426-9600
  • Fax: 194-264-1126
Mailing address:
  • Phone: 619-426-9600
  • Fax: 619-543-6529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA178184
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA178184
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA178184
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA178184
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: