Healthcare Provider Details

I. General information

NPI: 1619904109
Provider Name (Legal Business Name): JACQUELINE M GRUPP-PHELAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE BLDG. 25, 1ST FLOOR
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE BLDG. 25, 1ST FLOOR
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8111
  • Fax: 628-206-9038
Mailing address:
  • Phone: 628-206-8111
  • Fax: 628-206-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberG149165
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG149165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: