Provider Demographics
NPI:1477541415
Name:STOTTS JOYO, JACKLYN (MD)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:STOTTS JOYO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:
Other - Last Name:STOTTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3401 S HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7933
Mailing Address - Country:US
Mailing Address - Phone:714-427-7902
Mailing Address - Fax:714-427-7915
Practice Address - Street 1:3401 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7933
Practice Address - Country:US
Practice Address - Phone:714-427-7902
Practice Address - Fax:714-427-7915
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48848207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04273Medicare UPIN
648848Medicare ID - Type Unspecified