Provider Demographics
NPI:1265826150
Name:JUAREZ, JAIMIE C (PA-C, MHS)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:C
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:PA-C, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W KETTLEMAN LN STE 200
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4337
Mailing Address - Country:US
Mailing Address - Phone:093-348-5402
Mailing Address - Fax:
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant