Provider Demographics
NPI:1659020576
Name:CRISOSTOMO, JENNIFER JARDELEZA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JARDELEZA
Last Name:CRISOSTOMO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 80011
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8011
Mailing Address - Country:US
Mailing Address - Phone:626-793-2885
Mailing Address - Fax:626-793-6262
Practice Address - Street 1:235 E BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2116
Practice Address - Country:US
Practice Address - Phone:626-915-4700
Practice Address - Fax:626-214-7815
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2024-07-29
Deactivation Date:2022-03-18
Deactivation Code:
Reactivation Date:2022-05-04
Provider Licenses
StateLicense IDTaxonomies
CA95019457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95019457OtherBRN
CAF08210863OtherAANPCB