Provider Demographics
NPI:1174384077
Name:MACKAY, JESSICA BRADLEY (RNFA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BRADLEY
Last Name:MACKAY
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8073 HILLANDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-1512
Mailing Address - Country:US
Mailing Address - Phone:703-650-8757
Mailing Address - Fax:
Practice Address - Street 1:15615 POMERADO RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2405
Practice Address - Country:US
Practice Address - Phone:858-613-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95269817163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Multi-Specialty