Healthcare Provider Details

I. General information

NPI: 1043010812
Provider Name (Legal Business Name): JEFFREY WAYNE MALLOCK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 03/25/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17821 E. 17TH ST., SUITE 250
TUSTIN CA
92780
US

IV. Provider business mailing address

17821 E. 17TH ST., SUITE 250
TUSTIN CA
92780
US

V. Phone/Fax

Practice location:
  • Phone: 714-505-2093
  • Fax: 714-573-0072
Mailing address:
  • Phone: 714-505-2093
  • Fax: 714-573-0072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC17747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: