Provider Demographics
NPI:1649638784
Name:JESTER, BILTISHIA
Entity type:Individual
Prefix:
First Name:BILTISHIA
Middle Name:
Last Name:JESTER
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:PO BOX 641
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93584-0641
Mailing Address - Country:US
Mailing Address - Phone:323-241-2361
Mailing Address - Fax:
Practice Address - Street 1:567 W LANCASTER BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2533
Practice Address - Country:US
Practice Address - Phone:323-241-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2019-11-18
Deactivation Date:2018-05-02
Deactivation Code:
Reactivation Date:2019-11-18
Provider Licenses
StateLicense IDTaxonomies
CAD3050892172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker