Provider Demographics
NPI:1376182402
Name:SANDOVAL, JEANNETTE
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 TWIN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8746
Mailing Address - Country:US
Mailing Address - Phone:510-648-9012
Mailing Address - Fax:
Practice Address - Street 1:22101 REDWOOD RD UNIT B
Practice Address - Street 2:UNIT B
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-7107
Practice Address - Country:US
Practice Address - Phone:510-648-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA839846163W00000X
CA95012896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse