Provider Demographics
NPI:1841508835
Name:JAMERSON, JACQLYN TAMARA (LVN)
Entity type:Individual
Prefix:MRS
First Name:JACQLYN
Middle Name:TAMARA
Last Name:JAMERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 W 44TH ST
Mailing Address - Street 2:#8
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-3646
Mailing Address - Country:US
Mailing Address - Phone:909-267-8809
Mailing Address - Fax:
Practice Address - Street 1:357 W 44TH ST
Practice Address - Street 2:#8
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-3646
Practice Address - Country:US
Practice Address - Phone:909-267-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN200973164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse