Healthcare Provider Details

I. General information

NPI: 1770494452
Provider Name (Legal Business Name): JESSICA LYNN SANDVIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3291 BUCKMAN SPRINGS RD
PINE VALLEY CA
91962-4003
US

IV. Provider business mailing address

PO BOX 1534
PINE VALLEY CA
91962-1534
US

V. Phone/Fax

Practice location:
  • Phone: 619-473-8601
  • Fax:
Mailing address:
  • Phone: 619-729-8067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number95028682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: