Healthcare Provider Details

I. General information

NPI: 1669350559
Provider Name (Legal Business Name): JACQUELINE KSAJIKIAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 RIVERSIDE DR STE A
TOLUCA LAKE CA
91602-2502
US

IV. Provider business mailing address

2050 RIMCREST DR
GLENDALE CA
91207-1046
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-7394
  • Fax:
Mailing address:
  • Phone: 310-739-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95032857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: