Provider Demographics
NPI:1598336828
Name:SMITH-DOUGLAS, JACQUELYN (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:SMITH-DOUGLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 RENWICK DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-5931
Mailing Address - Country:US
Mailing Address - Phone:323-251-0477
Mailing Address - Fax:
Practice Address - Street 1:150 PAULARINO AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3301
Practice Address - Country:US
Practice Address - Phone:949-556-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF07210327363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty