Provider Demographics
NPI:1164166492
Name:SITUMEANG, JESSE REVIN
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:REVIN
Last Name:SITUMEANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71952 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:29 PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-2076
Mailing Address - Country:US
Mailing Address - Phone:720-666-0999
Mailing Address - Fax:760-401-8212
Practice Address - Street 1:71952 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:29 PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2076
Practice Address - Country:US
Practice Address - Phone:720-666-0999
Practice Address - Fax:760-401-8212
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA243146164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse