Provider Demographics
NPI:1588085963
Name:JACKSON, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
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 1:701 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6015
Mailing Address - Country:US
Mailing Address - Phone:559-713-6806
Mailing Address - Fax:559-713-6809
Practice Address - Street 1:606 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-9206
Practice Address - Country:US
Practice Address - Phone:559-321-8162
Practice Address - Fax:559-472-3559
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19219225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist