NPI Code Detail JSON Logo

1043010812 NPI number — JEFFREY WAYNE MALLOCK DC

NPI Number: 1043010812
Health Care Provider/Practitioner: JEFFREY WAYNE MALLOCK DC

Information about “1043010812” NPI (JEFFREY WAYNE MALLOCK DC) exists in 1043010812 in HTML format HTML  |  1043010812 in plain Text format TXT  |  1043010812 in PDF (Portable Document Format) PDF  |  1043010812 in an XML format XML  formats.

NPI Number : 1043010812 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1043010812",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MALLOCK",
    "FirstName": "JEFFREY",
    "MiddleName": "WAYNE",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "DC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "17821 E. 17TH ST., SUITE 250",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "TUSTIN",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92780",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "714-505-2093",
    "MailingAddressFaxNumber": "714-573-0072",
    "FirstLinePracticeLocationAddress": "17821 E. 17TH ST., SUITE 250",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "TUSTIN",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "92780",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "714-505-2093",
    "PracticeLocationAddressFaxNumber": "714-573-0072",
    "EnumerationDate": "03/19/2025",
    "LastUpdateDate": "03/25/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "111N00000X",
        "TaxonomyName": "Chiropractor",
        "LicenseNumber": "DC17747",
        "LicenseNumberStateCode": "CA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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