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NPI Code Detail

MEDICARE: JACKSON TEA MSN, PMHNP-BC

MEDICARE: JACKSON TEA MSN, PMHNP-BC
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner95033550CA

General Provider Information

NPI Number : 1477365997
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACKSON TEA MSN, PMHNP-BC
Provider Business Mailing Address
First Line : 734 LANTANA ST
Second Line :
City : LA VERNE
State : CA
Zip : 91750-5727
Country : US
Telephone Number : 626-429-0088
Fax Number :
Provider Business Practice Location Address
First Line : 1720 W BALL RD STE 4C
Second Line :
City : ANAHEIM
State : CA
Zip : 92804-5591
Country : US
Telephone Number : 714-683-1472
Fax Number : 714-683-1473
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/22/2025
Last Update Date : 04/15/2025

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