Healthcare Provider Details

I. General information

NPI: 1265826150
Provider Name (Legal Business Name): JAIMIE C JUAREZ PA-C, MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

1901 W KETTLEMAN LN STE 200
LODI CA
95242-4337
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 93-348-5402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: