Provider Demographics
NPI:1033439468
Name:MORENO, JENNIFER GAYLE (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GAYLE
Last Name:MORENO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:GAYLE
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10384 FRANK LN
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-2722
Mailing Address - Country:US
Mailing Address - Phone:619-729-1761
Mailing Address - Fax:
Practice Address - Street 1:10384 FRANK LN
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-2722
Practice Address - Country:US
Practice Address - Phone:619-729-1761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA740023163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA740023OtherSTATE OF CALIFORNIA BOARD OF REGISTERED NURSING