Provider Demographics
NPI:1598961179
Name:MCVICKER, JAN TAYLOR (RN)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:TAYLOR
Last Name:MCVICKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17875 SUN WALK CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1370
Mailing Address - Country:US
Mailing Address - Phone:858-451-8772
Mailing Address - Fax:
Practice Address - Street 1:17875 SUN WALK CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1370
Practice Address - Country:US
Practice Address - Phone:858-451-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA321973163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS017120Medicaid
CARVN005230Medicaid