1659897593 NPI number — LAMECIA LASHAY JACKSON LMT, CA

Table of content: LAMECIA LASHAY JACKSON LMT, CA (NPI 1659897593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659897593 NPI number — LAMECIA LASHAY JACKSON LMT, CA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
LAMECIA
Provider Middle Name:
LASHAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT, CA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
LAMECIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT, CA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659897593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5830 W THUNDERBIRD RD # B8216
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85306-4654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-203-8864
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 N ESTRELLA PKWY
Provider Second Line Business Practice Location Address:
#0-1
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-932-9211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2017

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: 225700000X , with the licence number:  MT-07028 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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