Healthcare Provider Details

I. General information

NPI: 1427925734
Provider Name (Legal Business Name): JASMINE KWACK PA-C
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N LINCOLN AVE STE 100
CORONA CA
92882-1853
US

IV. Provider business mailing address

110 N LINCOLN AVE STE 100
CORONA CA
92882-1853
US

V. Phone/Fax

Practice location:
  • Phone: 833-867-8462
  • Fax:
Mailing address:
  • Phone: 833-867-8462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: