Healthcare Provider Details

I. General information

NPI: 1437732690
Provider Name (Legal Business Name): JONAS JOSE JACOBA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 10/27/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-3515
  • Fax: 760-725-1515
Mailing address:
  • Phone: 760-719-3515
  • Fax: 760-719-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number829210
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: