Provider Demographics
NPI:1144689076
Name:SARKISSIAN, JACKLYN (PA-C)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:SARKISSIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:
Other - Last Name:KOURKCHIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5932 BALCOM AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1107
Mailing Address - Country:US
Mailing Address - Phone:818-208-0423
Mailing Address - Fax:
Practice Address - Street 1:13425 VENTURA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3995
Practice Address - Country:US
Practice Address - Phone:818-995-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-20
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant