Provider Demographics
NPI:1710525605
Name:CUELLAR, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CUELLAR
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 1:4795 MAUREEN CIR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-8016
Mailing Address - Country:US
Mailing Address - Phone:925-337-5460
Mailing Address - Fax:
Practice Address - Street 1:4795 MAUREEN CIR
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-8016
Practice Address - Country:US
Practice Address - Phone:925-337-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant