Healthcare Provider Details

I. General information

NPI: 1124909585
Provider Name (Legal Business Name): VICTORIA JAYNE HALLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 ENCLAVE CIR APT 205
COSTA MESA CA
92626-7088
US

IV. Provider business mailing address

1621 W CARROLL AVE
CHICAGO IL
60612-2501
US

V. Phone/Fax

Practice location:
  • Phone: 832-879-8019
  • Fax:
Mailing address:
  • Phone: 630-886-4978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-315652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: