MEDICARE: JACQUELINE MARIE HERNANDEZ

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	207R00000X	Internal Medicine Physician	95022528	CA
2	363LF0000X	Family Nurse Practitioner	95022528	CA

General Provider Information

NPI Number	:	1871293779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MARIE HERNANDEZ

Provider Business Mailing Address
First Line	:	20060 SYMERON RD
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92307-2613
Country	:	US
Telephone Number	:	760-927-6112
Fax Number	:

Provider Business Practice Location Address
First Line	:	15398 MAIN ST
Second Line	:
City	:	HESPERIA
State	:	CA
Zip	:	92345-3390
Country	:	US
Telephone Number	:	760-927-6112
Fax Number	:

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

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/05/2026

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