Healthcare Provider Details

I. General information

NPI: 1235968785
Provider Name (Legal Business Name): JACQUELINE NICOLE MOURRA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 BROADWAY
CHULA VISTA CA
91910-4304
US

IV. Provider business mailing address

9373 HAZARD WAY STE 200
SAN DIEGO CA
92123-1226
US

V. Phone/Fax

Practice location:
  • Phone: 619-427-1144
  • Fax: 619-427-1185
Mailing address:
  • Phone: 858-810-8000
  • Fax: 858-268-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95026949
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: