Healthcare Provider Details

I. General information

NPI: 1063960268
Provider Name (Legal Business Name): JENNIFER EMILY MUSTARD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 52ND ST STE 4100
OAKLAND CA
94609-1810
US

IV. Provider business mailing address

744 52ND ST STE 4100
OAKLAND CA
94609-1810
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3022
  • Fax:
Mailing address:
  • Phone: 510-428-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA188794
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA188794
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: