Healthcare Provider Details

I. General information

NPI: 1386289114
Provider Name (Legal Business Name): MR. JASPER BERNALES PRIMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 10/06/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CLEMENTINE ST
OCEANSIDE CA
92054-2806
US

IV. Provider business mailing address

1161 BREWLEY LN
VISTA CA
92081-9027
US

V. Phone/Fax

Practice location:
  • Phone: 760-638-5935
  • Fax:
Mailing address:
  • Phone: 347-326-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95017769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: