Healthcare Provider Details

I. General information

NPI: 1982137212
Provider Name (Legal Business Name): AMANDA L JAMAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PARADISE RD
MODESTO CA
95351-3163
US

IV. Provider business mailing address

260 W COURT ST APT 26
WOODLAND CA
95695-2562
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4000
  • Fax:
Mailing address:
  • Phone: 916-209-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA159540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: