Provider Demographics
NPI:1316269525
Name:BREDEHOFT, JACQUELINE D (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:BREDEHOFT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 E RAINIER AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1114
Mailing Address - Country:US
Mailing Address - Phone:714-319-7208
Mailing Address - Fax:714-464-4478
Practice Address - Street 1:901 DOVE ST STE 299
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3036
Practice Address - Country:US
Practice Address - Phone:714-497-3307
Practice Address - Fax:714-464-4478
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN382294363LP0808X
CA14352363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health