Provider Demographics
NPI:1629398490
Name:LEON, JACQUELINE MARIE LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE LEON
Last Name:LEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DINOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 300
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3628
Mailing Address - Country:US
Mailing Address - Phone:949-599-2423
Mailing Address - Fax:949-599-2430
Practice Address - Street 1:25500 RANCHO NIGUEL RD STE 110
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7373
Practice Address - Country:US
Practice Address - Phone:949-448-8821
Practice Address - Fax:949-448-8831
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111658208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR463ZMedicare PIN