Basic Information
| Provider Information | |||||||||
| NPI: | 1063921088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGANDA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MACIAS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8700 DE SOTO AVE APT 221 | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913041932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187440864 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 S BUENA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188435111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2017 | ||||||||
| LastUpdateDate: | 09/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 95007475 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.