Healthcare Provider Details

I. General information

NPI: 1346172251
Provider Name (Legal Business Name): JACQUELINE NICOLE BAEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19626 VENTURA BLVD STE 225
TARZANA CA
91356-6038
US

IV. Provider business mailing address

10650 REAGAN ST # 386
LOS ALAMITOS CA
90720-9998
US

V. Phone/Fax

Practice location:
  • Phone: 747-215-2070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: