Provider Demographics
NPI:1255492666
Name:EHTESHAMI, JENNIFER ANNE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ANNE
Last Name:EHTESHAMI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:WHITLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15477 VENTURA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3047
Mailing Address - Country:US
Mailing Address - Phone:760-835-4213
Mailing Address - Fax:
Practice Address - Street 1:15477 VENTURA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3047
Practice Address - Country:US
Practice Address - Phone:760-835-4213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-1929363A00000X
CAPA-17488363A00000X
CA63420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant