Healthcare Provider Details

I. General information

NPI: 1477365997
Provider Name (Legal Business Name): JACKSON TEA MSN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W BALL RD STE 4C
ANAHEIM CA
92804-5591
US

IV. Provider business mailing address

734 LANTANA ST
LA VERNE CA
91750-5727
US

V. Phone/Fax

Practice location:
  • Phone: 714-683-1472
  • Fax: 714-683-1473
Mailing address:
  • Phone: 626-429-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95033550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: