Healthcare Provider Details

I. General information

NPI: 1588516561
Provider Name (Legal Business Name): JAIRO OSCAR HERNANDEZ CAMACHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 MISSION GORGE RD STE 100
SAN DIEGO CA
92120-3425
US

IV. Provider business mailing address

6160 MISSION GORGE RD STE 100
SAN DIEGO CA
92120-3425
US

V. Phone/Fax

Practice location:
  • Phone: 619-481-3790
  • Fax: 619-481-3797
Mailing address:
  • Phone: 619-481-3790
  • Fax: 619-481-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-NZJUTD
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: