Provider Demographics
NPI:1992372650
Name:TAYLOR, JACQUELYN SUE (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 AMIRANTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4104
Mailing Address - Country:US
Mailing Address - Phone:310-901-0677
Mailing Address - Fax:
Practice Address - Street 1:23326 HAWTHORNE BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3723
Practice Address - Country:US
Practice Address - Phone:310-784-6835
Practice Address - Fax:310-784-4896
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95016954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily