Provider Demographics
NPI:1205678737
Name:PACHECO, JESSE ANTONIO
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ANTONIO
Last Name:PACHECO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 BOYINGTON PL
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1701
Mailing Address - Country:US
Mailing Address - Phone:402-616-7892
Mailing Address - Fax:
Practice Address - Street 1:USCGC ESCANABA
Practice Address - Street 2:4000 COAST GUARD BLVD
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2135
Practice Address - Country:US
Practice Address - Phone:757-483-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman