Provider Demographics
NPI:1699527010
Name:JACKSON, DELISA (NP)
Entity type:Individual
Prefix:
First Name:DELISA
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 1:6600 LONE TREE WAY STE A
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5256
Mailing Address - Country:US
Mailing Address - Phone:925-471-4223
Mailing Address - Fax:
Practice Address - Street 1:6600 LONE TREE WAY STE A
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5256
Practice Address - Country:US
Practice Address - Phone:925-471-4223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95028931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily