Provider Demographics
NPI:1710307905
Name:CLERC, JACQUELINE GAIL (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GAIL
Last Name:CLERC
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:NAVAL MEDICAL CTR
Mailing Address - Street 2:34800 BOB WILSON DRIVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-5000
Practice Address - Country:US
Practice Address - Phone:360-257-9688
Practice Address - Fax:360-257-9878
Is Sole Proprietor?:No
Enumeration Date:2014-04-26
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075626A207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN