Provider Demographics
NPI:1720861362
Name:EVANS, JACKIE DENISE (RN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:DENISE
Last Name:EVANS
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 1:480 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:808-473-1880
Mailing Address - Fax:808-473-4449
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-473-1880
Practice Address - Fax:808-473-4449
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254730163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care