Provider Demographics
NPI:1285644294
Name:JACQUEZ, JESSE J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:J
Last Name:JACQUEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 W VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2001
Mailing Address - Country:US
Mailing Address - Phone:909-824-3389
Mailing Address - Fax:909-824-1087
Practice Address - Street 1:895 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2001
Practice Address - Country:US
Practice Address - Phone:909-824-3389
Practice Address - Fax:909-824-1087
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10031363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659483352Medicaid
CAGR0071450Medicaid
CAZZZ14663ZMedicare PIN