Provider Demographics
NPI:1962169375
Name:MOGHADAM, JASMINE B (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:B
Last Name:MOGHADAM
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 1:1335 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3537
Mailing Address - Country:US
Mailing Address - Phone:909-542-2896
Mailing Address - Fax:
Practice Address - Street 1:1335 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3537
Practice Address - Country:US
Practice Address - Phone:909-542-2896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily