Provider Demographics
NPI:1396421525
Name:RENTZ, JACLYN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:RENTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12845 PINEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-1501
Mailing Address - Country:US
Mailing Address - Phone:951-906-6093
Mailing Address - Fax:
Practice Address - Street 1:12612 CHALLENGER PKWY STE 365
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-2784
Practice Address - Country:US
Practice Address - Phone:407-306-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant