Provider Demographics
NPI:1689303158
Name:JICK, MARINA (NP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:JICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S FAIR OAKS AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2666
Mailing Address - Country:US
Mailing Address - Phone:626-696-2747
Mailing Address - Fax:626-585-0695
Practice Address - Street 1:625 S FAIR OAKS AVE STE 255
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2666
Practice Address - Country:US
Practice Address - Phone:626-696-2747
Practice Address - Fax:626-585-0695
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004285363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty