Provider Demographics
NPI:1255717211
Name:HENDERSON, JASMINE PALMIANO
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:PALMIANO
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:PALMIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6195 LUSK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3715
Mailing Address - Country:US
Mailing Address - Phone:858-859-1188
Mailing Address - Fax:844-404-8924
Practice Address - Street 1:6195 LUSK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3715
Practice Address - Country:US
Practice Address - Phone:858-859-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54230363AM0700X
LA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical