=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225803935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JKBRAR, A PROFESSIONAL NURSING CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2023
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19712 MACARTHUR BLVD SUITE 110
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-229-2611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15615 ALTON PKWY STE 450
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-229-2611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESKEITH BRAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-229-2611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------