Provider Demographics
NPI:1134517451
Name:DALE, JENICA
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:
Last Name:DALE
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 1:5810 AMAYA DR APT 18E
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4143
Mailing Address - Country:US
Mailing Address - Phone:619-414-8121
Mailing Address - Fax:
Practice Address - Street 1:5810 AMAYA DR APT 18E
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-4143
Practice Address - Country:US
Practice Address - Phone:619-414-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282198164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse