Provider Demographics
NPI:1710982954
Name:ESTRADA, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DAYOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1075 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3538
Mailing Address - Country:US
Mailing Address - Phone:619-881-4500
Mailing Address - Fax:619-291-0959
Practice Address - Street 1:3772 TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2605
Practice Address - Country:US
Practice Address - Phone:888-743-7526
Practice Address - Fax:619-291-0959
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1719363AM0700X
CA17936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41988300Medicaid
WI41988300Medicaid
Q19969Medicare UPIN