Healthcare Provider Details

I. General information

NPI: 1043114622
Provider Name (Legal Business Name): TATONYA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 TOBIAS DR APT 21
CHULA VISTA CA
91911-4434
US

IV. Provider business mailing address

1419 TOBIAS DR APT 21
CHULA VISTA CA
91911-4434
US

V. Phone/Fax

Practice location:
  • Phone: 619-763-9579
  • Fax:
Mailing address:
  • Phone: 619-763-9579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: