Healthcare Provider Details

I. General information

NPI: 1497325187
Provider Name (Legal Business Name): LASHAUNDA RENEE JETHRO PMHNP, DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 POLK AVE
SAN DIEGO CA
92105-1524
US

IV. Provider business mailing address

31378 BRUSH CREEK CIR
TEMECULA CA
92591-7418
US

V. Phone/Fax

Practice location:
  • Phone: 619-563-0250
  • Fax: 858-633-4681
Mailing address:
  • Phone: 618-789-1081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95127420
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95017852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: