Provider Demographics
NPI:1861882029
Name:SUTHERLAND, JACKLINE SHINYONYA (NP)
Entity type:Individual
Prefix:MRS
First Name:JACKLINE
Middle Name:SHINYONYA
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 TOURNAMENT DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-5635
Mailing Address - Country:US
Mailing Address - Phone:661-526-4766
Mailing Address - Fax:
Practice Address - Street 1:320 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4598
Practice Address - Country:US
Practice Address - Phone:661-526-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 3442363LF0000X
MNR2068891363LF0000X
CA95011529363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1537966505Medicaid