Provider Demographics
NPI:1952852600
Name:NGO, JACKLYN MARUAL (ACNP)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MARUAL
Last Name:NGO
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAGNEY LN APT 108
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2683
Mailing Address - Country:US
Mailing Address - Phone:818-271-7262
Mailing Address - Fax:
Practice Address - Street 1:16420 HALSTED ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-1817
Practice Address - Country:US
Practice Address - Phone:818-271-7262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005212363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care