Provider Demographics
NPI:1609598408
Name:JACOBS, MIA LANISE (LVN)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:LANISE
Last Name:JACOBS
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 1:34264 CHAPAROSSA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2919
Mailing Address - Country:US
Mailing Address - Phone:951-259-6061
Mailing Address - Fax:
Practice Address - Street 1:26921 CROWN VALLEY PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6501
Practice Address - Country:US
Practice Address - Phone:949-334-8288
Practice Address - Fax:949-334-8294
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689359164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse