Provider Demographics
NPI:1619786761
Name:VANG, JEDIDIAH
Entity type:Individual
Prefix:MR
First Name:JEDIDIAH
Middle Name:
Last Name:VANG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 33RD ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1220
Mailing Address - Country:US
Mailing Address - Phone:916-279-4671
Mailing Address - Fax:
Practice Address - Street 1:3050 BEACON BLVD STE 150
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3467
Practice Address - Country:US
Practice Address - Phone:916-462-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist