Provider Demographics
NPI:1598451445
Name:ILOG, JUSTENE ANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:JUSTENE
Middle Name:ANN
Last Name:ILOG
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 MESA DR APT 105
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-2624
Mailing Address - Country:US
Mailing Address - Phone:951-768-0182
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 103
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5735
Practice Address - Country:US
Practice Address - Phone:760-295-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95219111163WP0808X
CA95025318363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health