Provider Demographics
NPI:1912736703
Name:CUNNINGHAM, JAZMIN JENAE
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:JENAE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAZMIN
Other - Middle Name:JENAE
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11175 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:909-558-8142
Mailing Address - Fax:
Practice Address - Street 1:11401 HEACOCK ST STE 330
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7908
Practice Address - Country:US
Practice Address - Phone:951-247-8697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95032520363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics