Individual
TARA JACKSON GLENN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
9300 CAMPUS POINT DR, LA JOLLA, CA 92037-1300
(858) 249-5800
Mailing address
3020 CHILDRENS WAY # MC5003, SAN DIEGO, CA 92123-4223
(858) 309-6300
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
35-126046
OH
208000000X
Pediatrics Physician
A170207
CA
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
A170207
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0148250
—
OH
Enumeration date
07/06/2012
Last updated
04/08/2021
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