MEDICARE: JACQUELINE LICAUCO NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95000859	CA

General Provider Information

NPI Number	:	1467857284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE LICAUCO NP

Provider Business Mailing Address
First Line	:	PO BOX 9602
Second Line	:
City	:	MISSION HILLS
State	:	CA
Zip	:	91346-9602
Country	:	US
Telephone Number	:	818-837-5559
Fax Number	:	818-792-4793

Provider Business Practice Location Address
First Line	:	191 S BUENA VISTA
Second Line	:	SUITE 100
City	:	BURBANK
State	:	CA
Zip	:	91505-4554
Country	:	US
Telephone Number	:	818-869-7600
Fax Number	:	814-433-3691

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	06/15/2026

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