Healthcare Provider Details

I. General information

NPI: 1699481887
Provider Name (Legal Business Name): JACQUELINE M HOOGERVORST AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

33034 CLAIRETTE CT
WINCHESTER CA
92596-4523
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95024083
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number784279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: