Provider Demographics
NPI:1366577512
Name:SANTOS, JESSICA ODOM (FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ODOM
Last Name:SANTOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0680
Mailing Address - Country:US
Mailing Address - Phone:916-933-8010
Mailing Address - Fax:
Practice Address - Street 1:5137 GOLDEN FOOTHILL PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9670
Practice Address - Country:US
Practice Address - Phone:916-933-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMS1507055OtherDEA