Provider Demographics
NPI:1992419626
Name:HAGAN, JENNICA ALYSE (DNP, APRN, NNP-BC)
Entity type:Individual
Prefix:DR
First Name:JENNICA
Middle Name:ALYSE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:DNP, APRN, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 DATA DR APT 1428
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6449
Mailing Address - Country:US
Mailing Address - Phone:636-352-8117
Mailing Address - Fax:
Practice Address - Street 1:4301 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2214
Practice Address - Country:US
Practice Address - Phone:916-734-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023812363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal