Healthcare Provider Details

I. General information

NPI: 1295147809
Provider Name (Legal Business Name): JAYASREE VASUDEVAN NAIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2014
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MISSION BLVD STE 2600
JACKSON CA
95642-2536
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-1722
  • Fax: 209-257-1726
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58699
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA155858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: