Healthcare Provider Details

I. General information

NPI: 1922803071
Provider Name (Legal Business Name): JAACE KOREERAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W GUINIDA LN
ANAHEIM CA
92805-6101
US

IV. Provider business mailing address

1931 PAGE AVE
FULLERTON CA
92833-4435
US

V. Phone/Fax

Practice location:
  • Phone: 714-517-8950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number110757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: