Provider Demographics
NPI:1497417174
Name:GARY, JACQUELYNE MARIE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYNE
Middle Name:MARIE
Last Name:GARY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JACQUELYNE
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 N 12TH AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5996
Mailing Address - Country:US
Mailing Address - Phone:559-355-3258
Mailing Address - Fax:
Practice Address - Street 1:5525 E MCKENZIE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-3305
Practice Address - Country:US
Practice Address - Phone:559-355-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA241563164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty