Healthcare Provider Details

I. General information

NPI: 1396725636
Provider Name (Legal Business Name): BETH RACHELLE JAKLIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FIRST COLONIAL RD STE 201
VIRGINIA BEACH VA
23454-2263
US

IV. Provider business mailing address

2808 OCEAN MIST CT
VIRGINIA BEACH VA
23454-1230
US

V. Phone/Fax

Practice location:
  • Phone: 757-419-4919
  • Fax: 757-419-4898
Mailing address:
  • Phone: 757-650-3047
  • Fax: 757-419-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101046986
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: