Provider Demographics
NPI:1467827188
Name:CUSANO, JACLYN ANN (PA)
Entity Type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:ANN
Last Name:CUSANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANN
Other - Last Name:KRAWIEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11645 MONTANA AVE APT 326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4656
Mailing Address - Country:US
Mailing Address - Phone:860-478-5864
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant