Basic Information
| Provider Information | |||||||||
| NPI: | 1750046561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | JEANELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8842 WINDING WAY APT 431 | ||||||||
| Address2: | |||||||||
| City: | FAIR OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956286473 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168749670 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2021 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 721219 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.