Healthcare Provider Details

I. General information

NPI: 1396421525
Provider Name (Legal Business Name): JACLYN NICOLE RENTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12612 CHALLENGER PKWY STE 365
ORLANDO FL
32826-2784
US

IV. Provider business mailing address

12845 PINEFIELD RD
POWAY CA
92064-1501
US

V. Phone/Fax

Practice location:
  • Phone: 407-306-8441
  • Fax:
Mailing address:
  • Phone: 951-906-6093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: