Provider Demographics
NPI:1740211077
Name:EASTLACK, JENNIFER POEHLER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:POEHLER
Last Name:EASTLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12395 EL CAMINO REAL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3082
Mailing Address - Country:US
Mailing Address - Phone:858-925-7227
Mailing Address - Fax:858-925-7227
Practice Address - Street 1:12395 EL CAMINO REAL
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3082
Practice Address - Country:US
Practice Address - Phone:858-481-3376
Practice Address - Fax:858-755-5947
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA75157207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH69813Medicare UPIN