Healthcare Provider Details

I. General information

NPI: 1801687496
Provider Name (Legal Business Name): JESSICA KYLANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26781 PORTOLA PKWY STE 4E
FOOTHILL RANCH CA
92610-1758
US

IV. Provider business mailing address

33591 AVENIDA CALITA
SAN JUAN CAPISTRANO CA
92675-4901
US

V. Phone/Fax

Practice location:
  • Phone: 949-297-3888
  • Fax:
Mailing address:
  • Phone: 949-226-3765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: