Provider Demographics
NPI:1801427448
Name:JACKSON, KALYSE DANAE (RN, NP)
Entity type:Individual
Prefix:MRS
First Name:KALYSE
Middle Name:DANAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:CALICE
Other - Middle Name:DANAE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:43943 CATSUE PL
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5566
Mailing Address - Country:US
Mailing Address - Phone:661-400-7095
Mailing Address - Fax:
Practice Address - Street 1:1405 W RANCHO VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3968
Practice Address - Country:US
Practice Address - Phone:373-783-9423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-02
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA837226163WX0003X
CA95014247363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient