Provider Demographics
NPI:1215651781
Name:MEDLEY-JACKSON, NADINE ALICIA
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:ALICIA
Last Name:MEDLEY-JACKSON
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 1:7143 PASEO DEL RIO
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-7816
Mailing Address - Country:US
Mailing Address - Phone:213-705-7503
Mailing Address - Fax:
Practice Address - Street 1:7143 PASEO DEL RIO
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-7816
Practice Address - Country:US
Practice Address - Phone:213-705-7503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95022482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner