Provider Demographics
NPI:1659692317
Name:LEKOSTAJ, JACQUELINE KATHLEEN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KATHLEEN
Last Name:LEKOSTAJ
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 RUTHERFORD RD
Mailing Address - Street 2:SAN03-1051
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-7328
Mailing Address - Country:US
Mailing Address - Phone:760-516-5113
Mailing Address - Fax:
Practice Address - Street 1:2110 RUTHERFORD RD
Practice Address - Street 2:SAN03-1051
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7328
Practice Address - Country:US
Practice Address - Phone:760-516-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137006207ZP0007X
IL036132840207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA137006OtherMEDICAL BOARD OF CALIFORNIA
IL125057763OtherMEDICAL LICENSE, TEMPORARY
IL036132840OtherMEDICAL LICENSE, PERMANENT
IAMD-41874OtherIOWA BOARD OF MEDICINE