Healthcare Provider Details

I. General information

NPI: 1568106995
Provider Name (Legal Business Name): JESSICA RUANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 TELEGRAPH AVE
BERKELEY CA
94705-2017
US

IV. Provider business mailing address

2905 TELEGRAPH AVE
BERKELEY CA
94705-2017
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-4525
  • Fax:
Mailing address:
  • Phone: 510-841-4525
  • Fax: 510-848-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95017725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: