Provider Demographics
NPI:1417727595
Name:JACKSON, CARRIE (CA-CPT1)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CA-CPT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 VALLEY VISTA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3921
Mailing Address - Country:US
Mailing Address - Phone:840-236-0671
Mailing Address - Fax:
Practice Address - Street 1:1370 VALLEY VISTA DR STE 200
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3921
Practice Address - Country:US
Practice Address - Phone:840-236-0671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT00064512246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy