Basic Information
| Provider Information | |||||||||
| NPI: | 1003116302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | LEANNE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 MISSION AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920587102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609674475 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 MISSION AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920587102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609674475 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 244694 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.