Provider Demographics
NPI:1154747103
Name:JACKSON, REBECCA (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-1704
Mailing Address - Country:US
Mailing Address - Phone:857-939-9274
Mailing Address - Fax:
Practice Address - Street 1:3655 NOBEL DRIVE, SUITE 660
Practice Address - Street 2:PEAK HEALTH SOLUTIONS
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122
Practice Address - Country:US
Practice Address - Phone:888-435-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37844363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health