Healthcare Provider Details

I. General information

NPI: 1609201417
Provider Name (Legal Business Name): JACLYN JEAN TOLENTINO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 05/06/2024
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S PACIFIC COAST HWY
EL SEGUNDO CA
90245-4717
US

IV. Provider business mailing address

321 FOWLING ST
PLAYA DEL REY CA
90293-7729
US

V. Phone/Fax

Practice location:
  • Phone: 310-563-7366
  • Fax:
Mailing address:
  • Phone: 305-458-7824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A16308
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: