MEDICARE: JENNIFER JOYCE JACKSON BA

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1811182884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER JOYCE JACKSON BA

Provider Business Mailing Address
First Line	:	1502 N WILLOW AVE
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-1459
Country	:	US
Telephone Number	:	310-631-3673
Fax Number	:

Provider Business Practice Location Address
First Line	:	631 S BROOKHURST ST
Second Line	:	SUITE 106
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3510
Country	:	US
Telephone Number	:	714-490-7711
Fax Number	:	714-490-7717

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

Provider Enumeration Date	:	09/12/2007
Last Update Date	:	09/12/2007

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