Healthcare Provider Details

I. General information

NPI: 1548401953
Provider Name (Legal Business Name): JACQUELINE TOM JEW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 KERNER BLVD
SAN RAFAEL CA
94901-4861
US

IV. Provider business mailing address

899 NORTHGATE DR STE 100
SAN RAFAEL CA
94903-3664
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6338
  • Fax: 415-473-2179
Mailing address:
  • Phone: 415-473-6338
  • Fax: 415-473-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN302387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: