Healthcare Provider Details

I. General information

NPI: 1265967079
Provider Name (Legal Business Name): JASON JUSTIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2017
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 REDWOOD HWY FRONTAGE RD STE 1204
MILL VALLEY CA
94941-2483
US

IV. Provider business mailing address

434 S SAN VICENTE BLVD # 100
LOS ANGELES CA
90048-4108
US

V. Phone/Fax

Practice location:
  • Phone: 415-384-4778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA54845
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: