Provider Demographics
NPI:1407155955
Name:REID, JASMINE L (PA-C)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:L
Last Name:REID
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18660 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2316
Mailing Address - Country:US
Mailing Address - Phone:760-946-2112
Mailing Address - Fax:760-946-2113
Practice Address - Street 1:18660 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2316
Practice Address - Country:US
Practice Address - Phone:760-946-2112
Practice Address - Fax:760-946-2113
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant