Provider Demographics
NPI:1699964908
Name:JACKSON, JOY MARIE (MD)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15206 PARTHENIA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5305
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-893-9464
Practice Address - Street 1:15206 PARTHENIA ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5305
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-893-9464
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70436FMedicaid
CAEAP70436FMedicaid
CAFHC70436FMedicaid
CAW11698OtherGROUP ID