Individual
JACQUELYN LEE VANDER WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3460 KATELLA AVE, LOS ALAMITOS, CA 90720-2334
(702) 579-3203
Mailing address
PO BOX 35380, LAS VEGAS, NV 89133-5380
(702) 579-3203
Taxonomy
Speciality
Code
Description
License number
State
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
G065045
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G65045G
—
CA
Enumeration date
03/12/2007
Last updated
11/30/2025
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