Provider Demographics
NPI:1194130906
Name:RENDIN, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RENDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15642 SAND CANYON AVE
Mailing Address - Street 2:PO BOX #51142
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17772 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6819
Practice Address - Country:US
Practice Address - Phone:714-843-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA147784207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194130906Medicaid
CAA147784OtherCALIFORNIA MEDICAL LICENSE