Provider Demographics
NPI:1962960906
Name:PENG, JESSIE (NP-C)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-652-8600
Mailing Address - Fax:
Practice Address - Street 1:1501 TROUSDALE DR
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4506
Practice Address - Country:US
Practice Address - Phone:650-652-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95176159163W00000X
WAAP60937038363LF0000X
OHAPRN.CNP.024197363LF0000X
CA95011315363LF0000X
CANP95011315363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily