Provider Demographics
NPI:1962456475
Name:ISHAK, JEANINE A (NP)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:A
Last Name:ISHAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:ADRIANA
Other - Last Name:SCHUTTENHELM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2811 N VENTURA RD
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2213
Mailing Address - Country:US
Mailing Address - Phone:805-983-0343
Mailing Address - Fax:805-983-3285
Practice Address - Street 1:32144 AGOURA RD
Practice Address - Street 2:STE 106
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4040
Practice Address - Country:US
Practice Address - Phone:805-379-3376
Practice Address - Fax:805-379-3267
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN793ZMedicare PIN