Provider Demographics
NPI:1932947488
Name:JACKSON, KHALED (RN)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 348563
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-8563
Mailing Address - Country:US
Mailing Address - Phone:708-516-0727
Mailing Address - Fax:
Practice Address - Street 1:650 HOWE AVE # 400-A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4731
Practice Address - Country:US
Practice Address - Phone:916-441-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95859029163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse