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NPI Code Detail

MEDICARE: TITUS CLINTON JACKSON PA-C

MEDICARE: TITUS CLINTON JACKSON PA-C
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
1363AS0400XSurgical Physician Assistant99220CA

General Provider Information

NPI Number : 1700224011
Entity Type Code : Individual
Provider Name (Legal Business Name) : TITUS CLINTON JACKSON PA-C
Provider Business Mailing Address
First Line : 444 S SAN VICENTE BLVD STE 603
Second Line :
City : LOS ANGELES
State : CA
Zip : 90048-4178
Country : US
Telephone Number : 310-423-4566
Fax Number :
Provider Business Practice Location Address
First Line : 444 S SAN VICENTE BLVD STE 603
Second Line :
City : LOS ANGELES
State : CA
Zip : 90048-4178
Country : US
Telephone Number : 310-423-4566
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2013
Last Update Date : 03/01/2024

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Directions to “ TITUS CLINTON JACKSON PA-C” Practice Location

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