Healthcare Provider Details

I. General information

NPI: 1447163944
Provider Name (Legal Business Name): JISA JOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9510 ELK GROVE FLORIN RD
ELK GROVE CA
95624-1801
US

IV. Provider business mailing address

4500 TRUXEL RD APT 235
SACRAMENTO CA
95834-3732
US

V. Phone/Fax

Practice location:
  • Phone: 916-686-5085
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number40874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: