Provider Demographics
NPI:1578094058
Name:SCULLY, JESICA
Entity type:Individual
Prefix:
First Name:JESICA
Middle Name:
Last Name:SCULLY
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 1:567 E VAN BIBBER AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:567 E VAN BIBBER AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2027
Practice Address - Country:US
Practice Address - Phone:408-497-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2024-07-05
Deactivation Date:2023-09-12
Deactivation Code:
Reactivation Date:2024-07-05
Provider Licenses
StateLicense IDTaxonomies
CA643484163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant