Healthcare Provider Details

I. General information

NPI: 1114362894
Provider Name (Legal Business Name): JENNA K TIMBOE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 AVENIDA VISTA HERMOSA STE 200
SAN CLEMENTE CA
92673-6338
US

IV. Provider business mailing address

505 S MAIN ST SUITE 525
ORANGE CA
92868-4509
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-7700
  • Fax: 949-429-7704
Mailing address:
  • Phone: 714-456-5631
  • Fax: 714-285-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA134953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: