Healthcare Provider Details

I. General information

NPI: 1710800057
Provider Name (Legal Business Name): JERON ROBERT JACHE CPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 HUENNEKENS ST STE 110
SAN DIEGO CA
92121-2928
US

IV. Provider business mailing address

9909 HUENNEKENS ST STE 110
SAN DIEGO CA
92121-2928
US

V. Phone/Fax

Practice location:
  • Phone: 858-500-8000
  • Fax: 858-864-1429
Mailing address:
  • Phone: 858-500-8000
  • Fax: 858-864-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-WTYVJK
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: