Provider Demographics
NPI:1972720597
Name:DE LA O, JESSE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:DE LA O
Suffix:
Gender:
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 1:23929 MCBEAN PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-4467
Mailing Address - Country:US
Mailing Address - Phone:661-200-2500
Mailing Address - Fax:
Practice Address - Street 1:23929 MCBEAN PKWY STE 102
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-4467
Practice Address - Country:US
Practice Address - Phone:661-200-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant