Healthcare Provider Details

I. General information

NPI: 1720735731
Provider Name (Legal Business Name): JAIME LUCIO HERRERA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13442 MALENA DR
SANTA ANA CA
92705-1912
US

IV. Provider business mailing address

114 SANTA ROSA WAY
PLACENTIA CA
92870-1838
US

V. Phone/Fax

Practice location:
  • Phone: 714-543-5437
  • Fax:
Mailing address:
  • Phone: 626-641-8836
  • Fax: 714-543-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95019147
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: