Healthcare Provider Details

I. General information

NPI: 1700527629
Provider Name (Legal Business Name): JACQUELINE SELIM ANTOUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CASTRO ST STE 232
SAN FRANCISCO CA
94114-1027
US

IV. Provider business mailing address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 415-565-6810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA187753
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: