Provider Demographics
NPI:1497325187
Name:JETHRO, LASHAUNDA RENEE (PMHNP, DNP)
Entity Type:Individual
Prefix:
First Name:LASHAUNDA
Middle Name:RENEE
Last Name:JETHRO
Suffix:
Gender:F
Credentials:PMHNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31378 BRUSH CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-7418
Mailing Address - Country:US
Mailing Address - Phone:618-789-1081
Mailing Address - Fax:
Practice Address - Street 1:4290 POLK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1524
Practice Address - Country:US
Practice Address - Phone:619-563-0250
Practice Address - Fax:858-633-4681
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95127420163W00000X
CANP95017852363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse