=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487396123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON DAVID TRUJILLO NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2022
-----------------------------------------------------
Last Update Date | 04/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 799 E GREEN ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-803-4648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 839 ALFORD ST
-----------------------------------------------------
City | GLENDORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91740-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-283-2863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95019715
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------