Healthcare Provider Details

I. General information

NPI: 1003299033
Provider Name (Legal Business Name): JESSICA WANG NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8399 GARVEY AVE
ROSEMEAD CA
91770-2650
US

IV. Provider business mailing address

22715 MOUNTAIN LAUREL WAY
DIAMOND BAR CA
91765-2527
US

V. Phone/Fax

Practice location:
  • Phone: 888-530-4415
  • Fax: 833-471-4510
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95002105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: