Provider Demographics
NPI:1568853745
Name:SWANSON, JACKIE LYNN SANTIAGO (NP-C)
Entity Type:Individual
Prefix:
First Name:JACKIE LYNN
Middle Name:SANTIAGO
Last Name:SWANSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JACKIE LYNN
Other - Middle Name:DIZON
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5559
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:26357 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4488
Practice Address - Country:US
Practice Address - Phone:661-222-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA703733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB236530Medicare PIN