Provider Demographics
NPI:1619359379
Name:JACQUEZ, JESSICA MARIE (LVN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:JACQUEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 MOTOR AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3710
Mailing Address - Country:US
Mailing Address - Phone:310-977-5565
Mailing Address - Fax:
Practice Address - Street 1:3200 MOTOR AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:310-977-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259127164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse