Provider Demographics
NPI:1114590395
Name:OXLEY, JAELYN DAVINA
Entity Type:Individual
Prefix:
First Name:JAELYN
Middle Name:DAVINA
Last Name:OXLEY
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 1:30 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1566
Mailing Address - Country:US
Mailing Address - Phone:951-907-5212
Mailing Address - Fax:
Practice Address - Street 1:30 MAPLE DR
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1566
Practice Address - Country:US
Practice Address - Phone:951-907-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman