Provider Demographics
NPI:1902456361
Name:SICURELLO, JASON ANTHONY
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANTHONY
Last Name:SICURELLO
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 1:7936 GOLD COAST DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3438
Mailing Address - Country:US
Mailing Address - Phone:480-341-7514
Mailing Address - Fax:
Practice Address - Street 1:161 N DATE ST
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3405
Practice Address - Country:US
Practice Address - Phone:760-745-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA229957164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty