Healthcare Provider Details

I. General information

NPI: 1639602378
Provider Name (Legal Business Name): JESSICA KWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 WILSHIRE BLVD STE 404
BEVERLY HILLS CA
90210-6137
US

IV. Provider business mailing address

9301 WILSHIRE BLVD STE 404
BEVERLY HILLS CA
90210-6137
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-9171
  • Fax:
Mailing address:
  • Phone: 142-420-2970
  • Fax: 310-278-2058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006433
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: