MEDICARE: MS. JENNIFER BETH JACKSON L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC10107	CA

General Provider Information

NPI Number	:	1356304596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER BETH JACKSON L.AC.

Provider Business Mailing Address
First Line	:	19 MEADOW DR
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-2824
Country	:	US
Telephone Number	:	415-686-6077
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 BRIDGEWAY
Second Line	:
City	:	SAUSALITO
State	:	CA
Zip	:	94965-1736
Country	:	US
Telephone Number	:	415-331-2024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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