1366555211 NPI number — ERIN HOSIE JACKSON MSPT, CPI

Table of content: ERIN HOSIE JACKSON MSPT, CPI (NPI 1366555211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366555211 NPI number — ERIN HOSIE JACKSON MSPT, CPI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ERIN
Provider Middle Name:
HOSIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT, CPI
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:
1366555211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 BANEBERRY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALISO VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92656-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-716-9616
Provider Business Mailing Address Fax Number:
949-494-3222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S COAST HWY
Provider Second Line Business Practice Location Address:
SUITE 301 B
Provider Business Practice Location Address City Name:
LAGUNA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92651-2968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-494-3200
Provider Business Practice Location Address Fax Number:
949-494-3222
Provider Enumeration Date:
08/16/2006

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: 225100000X , with the licence number:  20223 , 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: DQ684A . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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