Provider Demographics
NPI:1063084606
Name:JACKSON, SAVANNAH C
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:C
Last Name:JACKSON
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 1:11244 VISTA SORRENTO PKWY APT 102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-7629
Mailing Address - Country:US
Mailing Address - Phone:919-259-5180
Mailing Address - Fax:
Practice Address - Street 1:3605 VISTA WAY UNIT 258
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4565
Practice Address - Country:US
Practice Address - Phone:760-547-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program