Healthcare Provider Details

I. General information

NPI: 1306438395
Provider Name (Legal Business Name): JESSICA KOHLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2271 S DEPOT ST
SANTA MARIA CA
93455-1216
US

IV. Provider business mailing address

2271 S DEPOT ST
SANTA MARIA CA
93455-1216
US

V. Phone/Fax

Practice location:
  • Phone: 805-922-0561
  • Fax: 805-922-0083
Mailing address:
  • Phone: 805-922-0561
  • Fax: 805-922-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: