Provider Demographics
NPI:1710748561
Name:WALTERS, JACQUELYN ROSE (LVN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:WALTERS
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 1:800 S VICTORIA AVE # 4615
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93009-0003
Mailing Address - Country:US
Mailing Address - Phone:805-275-8262
Mailing Address - Fax:805-339-1128
Practice Address - Street 1:800 S VICTORIA AVE # 4615
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93009-0003
Practice Address - Country:US
Practice Address - Phone:805-275-8262
Practice Address - Fax:805-339-1128
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689979164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse