Healthcare Provider Details

I. General information

NPI: 1548008428
Provider Name (Legal Business Name): JENNIFER LEE QUACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SAINT DOMINICS DR STE 120
MANTECA CA
95337-7802
US

IV. Provider business mailing address

165 SAINT DOMINICS DR STE 120
MANTECA CA
95337-7802
US

V. Phone/Fax

Practice location:
  • Phone: 510-241-2884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: