Provider Demographics
NPI:1588178552
Name:GALLARDO, JACQUELINE (RN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:GALLARDO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:SALAZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1624 W RIALTO AVE APT 244
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-1925
Mailing Address - Country:US
Mailing Address - Phone:909-212-3331
Mailing Address - Fax:
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-421-9475
Practice Address - Fax:909-421-9392
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA830714163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty