Provider Demographics
NPI:1003116302
Name:JACK, LEANNE D (LVN)
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:D
Last Name:JACK
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 1:1701 MISSION AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7102
Mailing Address - Country:US
Mailing Address - Phone:760-967-4475
Mailing Address - Fax:
Practice Address - Street 1:1701 MISSION AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7102
Practice Address - Country:US
Practice Address - Phone:760-967-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244694164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse