Provider Demographics
NPI:1982306676
Name:IKEGWU, JACKLINE AUGUSTINA
Entity Type:Individual
Prefix:
First Name:JACKLINE
Middle Name:AUGUSTINA
Last Name:IKEGWU
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 1:18803 MOREHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3908
Mailing Address - Country:US
Mailing Address - Phone:310-940-1878
Mailing Address - Fax:
Practice Address - Street 1:3220 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2744
Practice Address - Country:US
Practice Address - Phone:310-940-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95236994163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health