Active NPI
Jeanette Jacknin, M.D.
- Dermatology Physician
- San Diego, CA
National Provider Identifier
1225493323
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- 22825
- Practice address
- 12634 Carmel Country Rd
Suite 126
San Diego, CA 92130-3197 - Phone
- (480) 577-3785
- NPI assigned
- Dec 16, 2015
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | 22825 | AZ | Primary |
Addresses
Primary practice location
12634 Carmel Country Rd
Suite 126
San Diego, CA 92130-3197
Mailing address
12634 Carmel Country Rd
Suite 126
San Diego, CA 92130-3197
Phone (480) 577-3785
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 22825 | AZ | MD | Dermatology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1450224000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1450224000000",
"number": "1225493323",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12634 CARMEL COUNTRY RD",
"address_2": "SUITE 126",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921303197",
"telephone_number": "480-577-3785"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12634 CARMEL COUNTRY RD",
"address_2": "SUITE 126",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921303197",
"telephone_number": "480-577-3785"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKNIN",
"first_name": "JEANETTE",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2015-12-16",
"last_updated": "2015-12-16",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "AZ",
"license": "22825",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.