Provider Demographics
NPI:1164567053
Name:WEISS, JACQUELYN A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3766
Mailing Address - Country:US
Mailing Address - Phone:510-208-4700
Mailing Address - Fax:510-208-4540
Practice Address - Street 1:180 GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3766
Practice Address - Country:US
Practice Address - Phone:510-208-4700
Practice Address - Fax:510-208-4540
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG456912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology