Provider Demographics
NPI:1891924957
Name:JAKKULA, JAGAN MOHANRAO
Entity type:Individual
Prefix:
First Name:JAGAN
Middle Name:MOHANRAO
Last Name:JAKKULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 W REDLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8054
Mailing Address - Country:US
Mailing Address - Phone:909-335-3026
Mailing Address - Fax:
Practice Address - Street 1:1809 W REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8054
Practice Address - Country:US
Practice Address - Phone:909-335-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN559232084P0800X
CAC1530852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI390200000XOtherMARSHFIELD
MN260003868Medicare PIN