Provider Demographics
NPI:1922759315
Name:JACKSON, RANEKIA DOMINIQUE (RN)
Entity Type:Individual
Prefix:
First Name:RANEKIA
Middle Name:DOMINIQUE
Last Name:JACKSON
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 1:6812 CEDAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-7282
Mailing Address - Country:US
Mailing Address - Phone:951-316-8112
Mailing Address - Fax:
Practice Address - Street 1:6812 CEDAR CREEK RD
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-7282
Practice Address - Country:US
Practice Address - Phone:951-316-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95140226163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse