Provider Demographics
NPI:1912159047
Name:JACKSON, PREATA LENAE (RN)
Entity type:Individual
Prefix:MISS
First Name:PREATA
Middle Name:LENAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17016 JURASSIC PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7723
Mailing Address - Country:US
Mailing Address - Phone:760-596-1033
Mailing Address - Fax:760-596-1033
Practice Address - Street 1:17016 JURASSIC PL
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-7723
Practice Address - Country:US
Practice Address - Phone:760-596-1033
Practice Address - Fax:760-596-1033
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA704221163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA704221OtherCALIFORNIA BOARD OF NURSING