Healthcare Provider Details

I. General information

NPI: 1922830330
Provider Name (Legal Business Name): JASMINE MIRIAM ESMAILZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE STE 230
LODI CA
95240-5142
US

IV. Provider business mailing address

4317 LANAI RD
ENCINO CA
91436-3616
US

V. Phone/Fax

Practice location:
  • Phone: 206-334-0127
  • Fax: 209-334-0127
Mailing address:
  • Phone: 818-561-0132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: