Provider Demographics
NPI:1760568059
Name:CASE, JACQUELINE LEE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LEE
Last Name:CASE
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 1:647 WARD WAY
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3247
Mailing Address - Country:US
Mailing Address - Phone:209-483-9809
Mailing Address - Fax:209-824-2805
Practice Address - Street 1:1808 POPPY LN
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2227
Practice Address - Country:US
Practice Address - Phone:209-483-9809
Practice Address - Fax:209-824-2805
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 149864164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS006020OtherMEDI-CAL