Provider Demographics
NPI:1790444602
Name:SIMMONS, JOHN T JR (LVN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:SIMMONS
Suffix:JR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 E HOLBROOK ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-1103
Mailing Address - Country:US
Mailing Address - Phone:714-261-5392
Mailing Address - Fax:
Practice Address - Street 1:5020 E HOLBROOK ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-1103
Practice Address - Country:US
Practice Address - Phone:714-261-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CA281328164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker