Provider Demographics
NPI:1407238942
Name:BRICK, JEANELLE LIAN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JEANELLE
Middle Name:LIAN
Last Name:BRICK
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 1:10 WHITECLOUD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5447
Mailing Address - Country:US
Mailing Address - Phone:949-533-5698
Mailing Address - Fax:
Practice Address - Street 1:10 WHITECLOUD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5447
Practice Address - Country:US
Practice Address - Phone:949-533-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-21
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant