Provider Demographics
NPI:1154013415
Name:MAINA, JACKSON MWANGI
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:MWANGI
Last Name:MAINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9568 MOSS HILL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95829-9364
Mailing Address - Country:US
Mailing Address - Phone:206-375-7124
Mailing Address - Fax:
Practice Address - Street 1:9568 MOSS HILL WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95829-9364
Practice Address - Country:US
Practice Address - Phone:206-375-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA732204164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty