Provider Demographics
NPI:1558880617
Name:ROLE, JETHRONE (MSN, RN)
Entity Type:Individual
Prefix:
First Name:JETHRONE
Middle Name:
Last Name:ROLE
Suffix:
Gender:M
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25841 SILVA CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6551
Mailing Address - Country:US
Mailing Address - Phone:323-346-5980
Mailing Address - Fax:
Practice Address - Street 1:101 E REDLANDS BLVD RM 1400B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3710
Practice Address - Country:US
Practice Address - Phone:909-651-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA676330163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator