Provider Demographics
NPI:1811182884
Name:JACKSON, JENNIFER JOYCE (BA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOYCE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1459
Mailing Address - Country:US
Mailing Address - Phone:310-631-3673
Mailing Address - Fax:
Practice Address - Street 1:631 S BROOKHURST ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3510
Practice Address - Country:US
Practice Address - Phone:714-490-7711
Practice Address - Fax:714-490-7717
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator