Healthcare Provider Details

I. General information

NPI: 1093246779
Provider Name (Legal Business Name): JASLEEN KAUR DHALIWAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JASLEEN KAUR KHAIRA JASLEEN KAUR

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E NORTH ST
MANTECA CA
95336-4900
US

IV. Provider business mailing address

1205 E NORTH ST
MANTECA CA
95336-4900
US

V. Phone/Fax

Practice location:
  • Phone: 951-973-2033
  • Fax:
Mailing address:
  • Phone: 951-973-2033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005648
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number1093246779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: