Healthcare Provider Details

I. General information

NPI: 1174803332
Provider Name (Legal Business Name): MRS. JESSIE JESUSYESENIA ORTIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8585 KNOTT AVE
BUENA PARK CA
90620-3896
US

IV. Provider business mailing address

8585 KNOTT AVE
BUENA PARK CA
90620-3896
US

V. Phone/Fax

Practice location:
  • Phone: 714-821-8588
  • Fax: 714-821-4482
Mailing address:
  • Phone: 714-821-8588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP95009346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: