Healthcare Provider Details

I. General information

NPI: 1063921088
Provider Name (Legal Business Name): JESSICA MACIAS MAGANDA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

8700 DE SOTO AVE APT 221
CANOGA PARK CA
91304-1932
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-5111
  • Fax:
Mailing address:
  • Phone: 818-744-0864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95007475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: