Provider Demographics
NPI:1174025076
Name:BAXTER, JAMELL (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:JAMELL
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 E SAN YSIDRO BLVD # 1260
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-565-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA620230163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health