Provider Demographics
NPI:1366915225
Name:CHURCHVILLE, JESSICA NICOLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:CHURCHVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-9235
Mailing Address - Country:US
Mailing Address - Phone:702-209-5809
Mailing Address - Fax:
Practice Address - Street 1:482 4TH AVE
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9235
Practice Address - Country:US
Practice Address - Phone:702-209-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide