Provider Demographics
NPI:1730664939
Name:MAXSON, JACQUELINE RENE (LVN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENE
Last Name:MAXSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:RENE
Other - Last Name:MAXSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1330 N INDIAN CANYON DR STE A
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4880
Mailing Address - Country:US
Mailing Address - Phone:760-322-9065
Mailing Address - Fax:
Practice Address - Street 1:1330 N INDIAN CANYON DR STE A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4880
Practice Address - Country:US
Practice Address - Phone:760-322-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA234891164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse