Provider Demographics
NPI:1740549583
Name:KAKISH, JOVANA GRACE (MD)
Entity type:Individual
Prefix:MRS
First Name:JOVANA
Middle Name:GRACE
Last Name:KAKISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOVANA
Other - Middle Name:GRACE
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:707-567-4957
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-567-4957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740549583OtherALL