1174760961 NPI number — MS. ANISHA NICOLE JACKSON PA

Table of content: MS. ANISHA NICOLE JACKSON PA (NPI 1174760961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174760961 NPI number — MS. ANISHA NICOLE JACKSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ANISHA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1174760961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/14/2019
NPI Reactivation Date:
09/30/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 PINE AVE
Provider Second Line Business Mailing Address:
APT 299
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-416-2021
Provider Business Mailing Address Fax Number:
217-569-4332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2573 W FLORIDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMET
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-658-7289
Provider Business Practice Location Address Fax Number:
951-756-5004
Provider Enumeration Date:
01/15/2009

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: 363A00000X , with the licence number:  56906 , 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)

  • Identifier: 56906 . This is a "STATE CA LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".