Healthcare Provider Details

I. General information

NPI: 1609598408
Provider Name (Legal Business Name): MIA LANISE JACOBS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26921 CROWN VALLEY PKWY STE 200
MISSION VIEJO CA
92691-6501
US

IV. Provider business mailing address

34264 CHAPAROSSA DR
LAKE ELSINORE CA
92532-2919
US

V. Phone/Fax

Practice location:
  • Phone: 949-334-8288
  • Fax: 949-334-8294
Mailing address:
  • Phone: 951-259-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number689359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: