Healthcare Provider Details

I. General information

NPI: 1588577720
Provider Name (Legal Business Name): JESSALYN SABRINA FUENTES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 CAMFIELD AVE
COMMERCE CA
90040-1502
US

IV. Provider business mailing address

2867 HICKORY PL APT C
COSTA MESA CA
92626-3824
US

V. Phone/Fax

Practice location:
  • Phone: 323-725-8751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number95410864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: