Healthcare Provider Details

I. General information

NPI: 1528884111
Provider Name (Legal Business Name): JASMINE PUTNAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 EL PICADOR CIR
FOUNTAIN VALLEY CA
92708-4826
US

IV. Provider business mailing address

10634 EL PICADOR CIR
FOUNTAIN VALLEY CA
92708-4826
US

V. Phone/Fax

Practice location:
  • Phone: 714-852-1975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number61995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: