Healthcare Provider Details

I. General information

NPI: 1740211077
Provider Name (Legal Business Name): JENNIFER POEHLER EASTLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE 200
SAN DIEGO CA
92130-3082
US

IV. Provider business mailing address

12395 EL CAMINO REAL SUITE 200
SAN DIEGO CA
92130-3082
US

V. Phone/Fax

Practice location:
  • Phone: 858-481-3376
  • Fax: 858-755-5947
Mailing address:
  • Phone: 858-925-7227
  • Fax: 858-925-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA75157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: