Healthcare Provider Details

I. General information

NPI: 1396520110
Provider Name (Legal Business Name): JERSSON NIETO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W METROPOLITAN DR STE 404
ORANGE CA
92868-3504
US

IV. Provider business mailing address

4000 W METROPOLITAN DR STE 404
ORANGE CA
92868-3504
US

V. Phone/Fax

Practice location:
  • Phone: 714-645-8045
  • Fax:
Mailing address:
  • Phone: 714-645-8045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: