Provider Demographics
NPI:1306718804
Name:BAUTISTA, JEREMIAH (RN, PHN, BSN)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:RN, PHN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 GREG THATCH CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-2425
Mailing Address - Country:US
Mailing Address - Phone:415-519-1054
Mailing Address - Fax:
Practice Address - Street 1:1100 SAN LEANDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1595
Practice Address - Country:US
Practice Address - Phone:510-267-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA951987202083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine