Provider Demographics
NPI:1366993800
Name:POURTAVERDI, JESSICA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:POURTAVERDI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 BURMAN DR
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-9276
Mailing Address - Country:US
Mailing Address - Phone:209-585-5606
Mailing Address - Fax:
Practice Address - Street 1:1000 W MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-0110
Practice Address - Country:US
Practice Address - Phone:209-669-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist