Healthcare Provider Details

I. General information

NPI: 1497436422
Provider Name (Legal Business Name): JENNIFER CERVANTES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 09/19/2023
Certification Date: 08/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 E CAPITOL EXPY STE 10
SAN JOSE CA
95121-1839
US

IV. Provider business mailing address

1680 E CAPITOL EXPY #10
SAN JOSE CA
95121
US

V. Phone/Fax

Practice location:
  • Phone: 408-645-7096
  • Fax:
Mailing address:
  • Phone: 408-645-7096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number63086
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number63086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: