1639457161 NPI number — MRS. JESSICA ANNE BAXTER NELSON RDHAP

Table of content: MRS. JESSICA ANNE BAXTER NELSON RDHAP (NPI 1639457161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639457161 NPI number — MRS. JESSICA ANNE BAXTER NELSON RDHAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
JESSICA
Provider Middle Name:
ANNE BAXTER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDHAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639457161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11310 PROSPECT DR
Provider Second Line Business Mailing Address:
SUITE 10 #211
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95642-9311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-717-5704
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 VISTA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IONE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95640-5424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-717-5704
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  HAP 360 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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