Provider Demographics
NPI:1538347307
Name:EBERSOLE, JACKIE LYNN (RN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:EBERSOLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 S FRANCISCO CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5352
Mailing Address - Country:US
Mailing Address - Phone:925-813-3337
Mailing Address - Fax:925-813-3331
Practice Address - Street 1:1605 S FRANCISCO CT
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-5352
Practice Address - Country:US
Practice Address - Phone:925-813-3337
Practice Address - Fax:925-813-3331
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462648163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse