Provider Demographics
NPI:1952916652
Name:KAGWA, JACKIE (RN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:KAGWA
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2026
Mailing Address - Country:US
Mailing Address - Phone:302-540-7604
Mailing Address - Fax:
Practice Address - Street 1:4131 PEARL ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2026
Practice Address - Country:US
Practice Address - Phone:302-540-7604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95401886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse