Provider Demographics
NPI:1790278190
Name:DANIEL, JESSICA JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANE
Last Name:DANIEL
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 1:4000 CIVIC CENTER DR STE 209
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5233
Mailing Address - Country:US
Mailing Address - Phone:415-925-8963
Mailing Address - Fax:
Practice Address - Street 1:4000 CIVIC CENTER DR STE 209
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5233
Practice Address - Country:US
Practice Address - Phone:415-925-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA195774363A00000X
CAPA60598363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant