Provider Demographics
NPI:1982732236
Name:SAMMONS, JACQUELYN DIANE (DO)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:DIANE
Last Name:SAMMONS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6200 E CANYON RIM RD STE 105B
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4313
Mailing Address - Country:US
Mailing Address - Phone:714-900-3091
Mailing Address - Fax:714-386-5147
Practice Address - Street 1:6200 E CANYON RIM RD STE 105B
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4313
Practice Address - Country:US
Practice Address - Phone:714-900-3091
Practice Address - Fax:714-386-5147
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9246207VG0400X
CA20A9246207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT824XMedicare PIN