Provider Demographics
NPI:1417928557
Name:REARDON, JACQUELINE MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:REARDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:435 H ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4307
Mailing Address - Country:US
Mailing Address - Phone:619-691-7290
Mailing Address - Fax:
Practice Address - Street 1:435 H ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4307
Practice Address - Country:US
Practice Address - Phone:619-691-7290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002390A208D00000X
CA20A10015207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice