Provider Demographics
NPI:1649908294
Name:ALEXANDRE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ALEXANDRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7761 VALLE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1837
Mailing Address - Country:US
Mailing Address - Phone:407-580-0406
Mailing Address - Fax:
Practice Address - Street 1:7761 VALLE VISTA DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1837
Practice Address - Country:US
Practice Address - Phone:407-580-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95074734163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse