Provider Demographics
NPI:1740392026
Name:DESBY, JENNIFER ELAINE (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:DESBY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:SUITE 703
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7720
Mailing Address - Country:US
Mailing Address - Phone:949-760-0190
Mailing Address - Fax:949-760-0439
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:SUITE 703
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-760-0190
Practice Address - Fax:949-760-0439
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA LIC # 17383OtherP.A. LICENSE #