Provider Demographics
NPI:1043010812
Name:MALLOCK, JEFFREY WAYNE (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:MALLOCK
Suffix:
Gender:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17821 E. 17TH ST., SUITE 250
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:714-505-2093
Mailing Address - Fax:714-573-0072
Practice Address - Street 1:17821 E. 17TH ST., SUITE 250
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-505-2093
Practice Address - Fax:714-573-0072
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty