Provider Demographics
NPI:1093246779
Name:DHALIWAL, JASLEEN KAUR
Entity Type:Individual
Prefix:
First Name:JASLEEN
Middle Name:KAUR
Last Name:DHALIWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASLEEN
Other - Middle Name:KAUR
Other - Last Name:KHAIRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JASLEEN KAUR
Mailing Address - Street 1:1205 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4900
Mailing Address - Country:US
Mailing Address - Phone:951-973-2033
Mailing Address - Fax:
Practice Address - Street 1:1205 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4900
Practice Address - Country:US
Practice Address - Phone:951-973-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1093246779207PE0004X
CA95005648363LF0000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093246779Medicaid