Healthcare Provider Details

I. General information

NPI: 1285467977
Provider Name (Legal Business Name): JACQUELINE BLANCO SERRATO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W LA VETA AVE STE 730
ORANGE CA
92868-4229
US

IV. Provider business mailing address

1140 W LA VETA AVE STE 730
ORANGE CA
92868-4229
US

V. Phone/Fax

Practice location:
  • Phone: 714-541-6800
  • Fax: 714-541-1119
Mailing address:
  • Phone: 714-541-6800
  • Fax: 714-541-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: