Healthcare Provider Details

I. General information

NPI: 1285644294
Provider Name (Legal Business Name): JESSE J. JACQUEZ P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 W VALLEY BLVD
COLTON CA
92324-2001
US

IV. Provider business mailing address

895 W VALLEY BLVD
COLTON CA
92324-2001
US

V. Phone/Fax

Practice location:
  • Phone: 909-824-3389
  • Fax: 909-824-1087
Mailing address:
  • Phone: 909-824-3389
  • Fax: 909-824-1087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: