Provider Demographics
NPI:1003365180
Name:JACY, EVANGELINA
Entity Type:Individual
Prefix:
First Name:EVANGELINA
Middle Name:
Last Name:JACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 BETHANY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-1514
Mailing Address - Country:US
Mailing Address - Phone:408-250-2568
Mailing Address - Fax:408-729-3282
Practice Address - Street 1:1820 BETHANY AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-1514
Practice Address - Country:US
Practice Address - Phone:408-250-2568
Practice Address - Fax:408-729-3282
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435201652310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility