Healthcare Provider Details

I. General information

NPI: 1073542262
Provider Name (Legal Business Name): JENNIFER LYN O'HERIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 E EDINGER AVE
SANTA ANA CA
92705-5001
US

IV. Provider business mailing address

14322 SHADYBROOK DR
TUSTIN CA
92780-6345
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-8904
  • Fax:
Mailing address:
  • Phone: 714-508-9042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: