Basic Information
| Provider Information | |||||||||
| NPI: | 1225771264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLESCO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SANTIAGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588108000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Practice Location | |||||||||
| Address1: | 752 MEDICAL CENTER CT | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194213361 | ||||||||
| FaxNumber: | 6198694378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2022 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95020676 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95020676 | 01 | CA | LICENSE | OTHER |