Provider Demographics
NPI:1366869398
Name:ZACKARY, JON (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:ZACKARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 CLAIREMONT MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-1003
Mailing Address - Country:US
Mailing Address - Phone:619-528-5164
Mailing Address - Fax:
Practice Address - Street 1:7060 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1003
Practice Address - Country:US
Practice Address - Phone:619-528-5164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138047390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program