Healthcare Provider Details

I. General information

NPI: 1649839077
Provider Name (Legal Business Name): JASEN TJAHJADI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 SAND CREEK RD STE A
BRENTWOOD CA
94513-2057
US

IV. Provider business mailing address

171 SAND CREEK RD STE A
BRENTWOOD CA
94513-2057
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-4940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT217899
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA176433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: