Provider Demographics
NPI:1013353671
Name:KHURI, JACKLEN JAMEL
Entity type:Individual
Prefix:
First Name:JACKLEN
Middle Name:JAMEL
Last Name:KHURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21641 CANADA RD APT 19E
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2774
Mailing Address - Country:US
Mailing Address - Phone:909-380-4419
Mailing Address - Fax:
Practice Address - Street 1:21641 CANADA RD APT 19E
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2774
Practice Address - Country:US
Practice Address - Phone:909-380-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA671397163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical