Provider Demographics
NPI:1275108680
Name:TEJEDA, JACQUELIN JANET (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:JANET
Last Name:TEJEDA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21641 BURCH ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-5648
Mailing Address - Country:US
Mailing Address - Phone:951-346-6921
Mailing Address - Fax:
Practice Address - Street 1:11980 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5172
Practice Address - Country:US
Practice Address - Phone:951-654-0803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95178939163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management