Healthcare Provider Details

I. General information

NPI: 1508599424
Provider Name (Legal Business Name): KELSEY JEPSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 WARNER AVE STE 368
FOUNTAIN VALLEY CA
92708-7514
US

IV. Provider business mailing address

8578 AMAZON RIVER CIR
FOUNTAIN VALLEY CA
92708-5510
US

V. Phone/Fax

Practice location:
  • Phone: 714-410-1025
  • Fax:
Mailing address:
  • Phone: 818-319-8192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95021529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: