Provider Demographics
NPI:1578038493
Name:MIRANDA, JENNIFER LEE (MSN, NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MSN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2215
Mailing Address - Country:US
Mailing Address - Phone:530-453-2000
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010019363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner