Healthcare Provider Details

I. General information

NPI: 1194418301
Provider Name (Legal Business Name): JACQUELINE CAONGUYEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE KOH OTR/L

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 FALLSVIEW PL
ESCONDIDO CA
92027-1066
US

IV. Provider business mailing address

1450 FALLSVIEW PL
ESCONDIDO CA
92027-1066
US

V. Phone/Fax

Practice location:
  • Phone: 626-239-8753
  • Fax:
Mailing address:
  • Phone: 626-239-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number16569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: