Healthcare Provider Details

I. General information

NPI: 1790167328
Provider Name (Legal Business Name): JESSICA BLAIR PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA WOODS

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CORPORATE DR STE 200
LADERA RANCH CA
92694-2179
US

IV. Provider business mailing address

21882 JINETES
MISSION VIEJO CA
92691-1114
US

V. Phone/Fax

Practice location:
  • Phone: 949-347-7200
  • Fax:
Mailing address:
  • Phone: 310-897-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95007023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: