Healthcare Provider Details

I. General information

NPI: 1710646435
Provider Name (Legal Business Name): JENNIFER SUSAN TUSTISON FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2549 EASTBLUFF DR STE B-757
NEWPORT BEACH CA
92660-3500
US

IV. Provider business mailing address

2549 EASTBLUFF DR STE B-757
NEWPORT BEACH CA
92660-3500
US

V. Phone/Fax

Practice location:
  • Phone: 949-409-7079
  • Fax: 949-220-2605
Mailing address:
  • Phone: 949-409-7079
  • Fax: 949-220-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017876
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95017876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: