Healthcare Provider Details

I. General information

NPI: 1154072601
Provider Name (Legal Business Name): JODI N MWENDIA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7172 MAGNOLIA AVE
RIVERSIDE CA
92504-3804
US

IV. Provider business mailing address

7922 DAY CREEK BLVD APT 1206
RANCHO CUCAMONGA CA
91739-8586
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-2224
  • Fax:
Mailing address:
  • Phone: 925-667-8446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: