Provider Demographics
NPI:1912371055
Name:JACKSON-RILEY, DELORES (RN)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:
Last Name:JACKSON-RILEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6902 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1150
Mailing Address - Country:US
Mailing Address - Phone:562-440-8501
Mailing Address - Fax:
Practice Address - Street 1:6902 EMERSON DR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1150
Practice Address - Country:US
Practice Address - Phone:562-440-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-29
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA848390163W00000X
MDR140724163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse