Provider Demographics
NPI:1356667539
Name:STUBBLEFIELD, JERMAINE J (PA)
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:J
Last Name:STUBBLEFIELD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL PLAZA
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3038
Mailing Address - Country:US
Mailing Address - Phone:916-797-4725
Mailing Address - Fax:916-797-4716
Practice Address - Street 1:2 MEDICAL PLAZA
Practice Address - Street 2:SUITE 130
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3038
Practice Address - Country:US
Practice Address - Phone:916-797-4725
Practice Address - Fax:916-797-4716
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20823363AM0700X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical