Healthcare Provider Details

I. General information

NPI: 1306007059
Provider Name (Legal Business Name): MS. CURTIS JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N GRAND AVE 110
COVINA CA
91724-1001
US

IV. Provider business mailing address

2648 E WORKMAN AVE # 143
WEST COVINA CA
91791-1604
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-736-3537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: