Healthcare Provider Details

I. General information

NPI: 1649085432
Provider Name (Legal Business Name): JESSICA A CISNEROS MA/ MANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 ATLANTIC AVE STE 100
LONG BEACH CA
90807-3529
US

IV. Provider business mailing address

3939 ATLANTIC AVE STE 100
LONG BEACH CA
90807-3529
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-1765
  • Fax: 562-633-7853
Mailing address:
  • Phone: 562-633-1765
  • Fax: 562-633-7853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000000000000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: