1134331259 NPI number — MS. COLLEEN DELORES JACKSON NURSE PRACTITIONER

Table of content: MS. COLLEEN DELORES JACKSON NURSE PRACTITIONER (NPI 1134331259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134331259 NPI number — MS. COLLEEN DELORES JACKSON NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
COLLEEN
Provider Middle Name:
DELORES
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1134331259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
849 MANZANITA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91103-2961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-423-8572
Provider Business Mailing Address Fax Number:
310-423-8550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 BEVERLY BLVD
Provider Second Line Business Practice Location Address:
THALIANS 2W, RM 218
Provider Business Practice Location Address City Name:
WEST HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-423-8572
Provider Business Practice Location Address Fax Number:
310-423-8550
Provider Enumeration Date:
05/03/2007

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: 363LF0000X , with the licence number:  12835 , 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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