Healthcare Provider Details

I. General information

NPI: 1174384077
Provider Name (Legal Business Name): JESSICA BRADLEY MACKAY RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15615 POMERADO RD
POWAY CA
92064-2405
US

IV. Provider business mailing address

8073 HILLANDALE DR
SAN DIEGO CA
92120-1512
US

V. Phone/Fax

Practice location:
  • Phone: 858-613-4000
  • Fax:
Mailing address:
  • Phone: 703-650-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number95269817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: