Provider Demographics
NPI:1598120818
Name:RENVILLE, JAESHAUN
Entity Type:Individual
Prefix:
First Name:JAESHAUN
Middle Name:
Last Name:RENVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 7TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-1753
Mailing Address - Country:US
Mailing Address - Phone:605-268-2331
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:605-742-0182
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDP011701164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse