Provider Demographics
NPI:1447760103
Name:WU, JACQUELINE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3167 VIA MONTANETA
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-7411
Mailing Address - Country:US
Mailing Address - Phone:858-397-8278
Mailing Address - Fax:
Practice Address - Street 1:6340 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-2102
Practice Address - Country:US
Practice Address - Phone:949-559-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55024207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine