Provider Demographics
NPI:1750038345
Name:DHALIWAL, JAISLEEN
Entity Type:Individual
Prefix:
First Name:JAISLEEN
Middle Name:
Last Name:DHALIWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6749 CELADON LN
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7705
Mailing Address - Country:US
Mailing Address - Phone:510-244-8094
Mailing Address - Fax:
Practice Address - Street 1:1317 OAKDALE RD STE 800
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3366
Practice Address - Country:US
Practice Address - Phone:833-478-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily