Provider Demographics
NPI:1942701719
Name:MANDAC, JAYART YADAO
Entity Type:Individual
Prefix:
First Name:JAYART
Middle Name:YADAO
Last Name:MANDAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1337
Mailing Address - Country:US
Mailing Address - Phone:915-875-1000
Mailing Address - Fax:
Practice Address - Street 1:2150 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:915-875-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA691188164X00000X
CA95208003163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse