Provider Demographics
NPI:1215113998
Name:SMASAL-KWAK, JILLAINE
Entity type:Individual
Prefix:
First Name:JILLAINE
Middle Name:
Last Name:SMASAL-KWAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2123
Mailing Address - Country:US
Mailing Address - Phone:619-494-1443
Mailing Address - Fax:
Practice Address - Street 1:451 RIVERVIEW PKWY
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-5829
Practice Address - Country:US
Practice Address - Phone:619-494-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABJ614ZMedicare UPIN