Healthcare Provider Details

I. General information

NPI: 1114842895
Provider Name (Legal Business Name): VICTOR JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 BATTLE CREEK RD
CHULA VISTA CA
91913-1676
US

IV. Provider business mailing address

1243 BATTLE CREEK RD
CHULA VISTA CA
91913-1676
US

V. Phone/Fax

Practice location:
  • Phone: 619-787-0901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278G1100X
TaxonomyGeneral Care Certified Respiratory Therapist
License Number31720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: