Basic Information
Provider Information | |||||||||
NPI: | 1841691342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | TOMIKO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LVN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUNN | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | TOMIKO | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LVN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1919 APPLE ST STE F&G | ||||||||
Address2: |   | ||||||||
City: | OCEANSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 920544492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605471280 | ||||||||
FaxNumber: | 7605471268 | ||||||||
Practice Location | |||||||||
Address1: | 1919 APPLE ST STE F&G | ||||||||
Address2: |   | ||||||||
City: | OCEANSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 920544492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605471280 | ||||||||
FaxNumber: | 7605471268 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2014 | ||||||||
LastUpdateDate: | 09/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN275092 | CA | Y |   | Nursing Service Providers | Licensed Vocational Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 4000 | 01 | CA | JENNIFER | OTHER |