Healthcare Provider Details

I. General information

NPI: 1366439051
Provider Name (Legal Business Name): JACLYNN J DO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10141 WESTMINSTER AVE SUITE E
GARDEN GROVE CA
92843-4788
US

IV. Provider business mailing address

10141 WESTMINSTER AVE
GARDEN GROVE CA
92843-4790
US

V. Phone/Fax

Practice location:
  • Phone: 714-467-4321
  • Fax: 714-467-4311
Mailing address:
  • Phone: 714-467-4321
  • Fax: 714-467-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA78520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: