Healthcare Provider Details

I. General information

NPI: 1467612325
Provider Name (Legal Business Name): MARK ALAN JACKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 COHASSET RD
CHICO CA
95926-2213
US

IV. Provider business mailing address

PO BOX A D
YUBA CITY CA
95992-1396
US

V. Phone/Fax

Practice location:
  • Phone: 530-342-4395
  • Fax: 530-894-2325
Mailing address:
  • Phone: 530-751-3769
  • Fax: 530-751-1237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: