Provider Demographics
NPI:1578726204
Name:JACKSON, KENDRA Y (LVN)
Entity Type:Individual
Prefix:MS
First Name:KENDRA
Middle Name:Y
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 S WINERY AVE
Mailing Address - Street 2:#104
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-8239
Mailing Address - Country:US
Mailing Address - Phone:559-455-7371
Mailing Address - Fax:
Practice Address - Street 1:568 S WINERY AVE
Practice Address - Street 2:#104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-8239
Practice Address - Country:US
Practice Address - Phone:559-455-7371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN199765164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse