Healthcare Provider Details

I. General information

NPI: 1285850974
Provider Name (Legal Business Name): ELENA B JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MAGNOLIA AVE SUITE 2A
CORONA CA
92879-3122
US

IV. Provider business mailing address

770 MAGNOLIA AVE STE 2A
CORONA CA
92879-3122
US

V. Phone/Fax

Practice location:
  • Phone: 951-736-8144
  • Fax: 951-736-0701
Mailing address:
  • Phone: 951-736-8144
  • Fax: 951-736-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA97558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: