Provider Demographics
NPI:1487773610
Name:JACKSON, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
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 1:6213 E CARITA ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2807
Mailing Address - Country:US
Mailing Address - Phone:562-507-0426
Mailing Address - Fax:
Practice Address - Street 1:800 S SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3536
Practice Address - Country:US
Practice Address - Phone:323-290-4378
Practice Address - Fax:323-293-8159
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator