Healthcare Provider Details

I. General information

NPI: 1669516381
Provider Name (Legal Business Name): JAMIE L TOKUBO L.AC,MSTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JAMIE L. SHUTT L.AC. MSTOM

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 SYCAMORE AVE STE 210
VISTA CA
92081-7851
US

IV. Provider business mailing address

PO BOX 546
CARDIFF CA
92007-0546
US

V. Phone/Fax

Practice location:
  • Phone: 858-436-7600
  • Fax: 760-797-1845
Mailing address:
  • Phone: 858-436-7600
  • Fax: 760-797-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number11199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: