Healthcare Provider Details

I. General information

NPI: 1114472669
Provider Name (Legal Business Name): JENNIFER KLISH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 02/11/2022
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 MORSE AVE
SACRAMENTO CA
95825-2115
US

IV. Provider business mailing address

6845 MELLODORA DR
ORANGEVALE CA
95662-3020
US

V. Phone/Fax

Practice location:
  • Phone: 916-973-5000
  • Fax:
Mailing address:
  • Phone: 530-209-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number736353
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: