1053773960 NPI number — JACLYN CORNEJO 89928 IMF

Table of content: JACLYN CORNEJO 89928 IMF (NPI 1053773960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053773960 NPI number — JACLYN CORNEJO 89928 IMF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNEJO
Provider First Name:
JACLYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
89928 IMF
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053773960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 KEMPER ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92110-4906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-523-8121
Provider Business Mailing Address Fax Number:
619-523-8742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3340 KEMPER ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-4906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-523-8121
Provider Business Practice Location Address Fax Number:
619-523-8742
Provider Enumeration Date:
03/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  89928 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 373781000 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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