Basic Information
Provider Information
NPI: 1538560396
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MACIAS
FirstName: JESSICA
MiddleName: BLAIR
NamePrefix:  
NameSuffix:  
Credential: LVN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 231 E ORLANDO ST
Address2:  
City: CHULA VISTA
State: CA
PostalCode: 919113617
CountryCode: US
TelephoneNumber: 6197217111
FaxNumber:  
Practice Location
Address1: 2865 LOGAN AVE
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921132411
CountryCode: US
TelephoneNumber: 6192324357
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/11/2014
LastUpdateDate: 09/11/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164X00000XVN277190CAY Nursing Service ProvidersLicensed Vocational Nurse 

No ID Information.


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