Provider Demographics
NPI:1548819857
Name:MORDEN, JACQUELINE RAE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RAE
Last Name:MORDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:RAE
Other - Last Name:MORDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1208
Mailing Address - Country:US
Mailing Address - Phone:858-554-1212
Mailing Address - Fax:858-795-1195
Practice Address - Street 1:9850 GENESEE AVE STE 320
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1208
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-795-1195
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant