Healthcare Provider Details

I. General information

NPI: 1679151187
Provider Name (Legal Business Name): TONYA ANNETTE JACKSON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 COURAGE DR
FAIRFIELD CA
94533-6717
US

IV. Provider business mailing address

4622 HAFLINGER DR
FAIRFIELD CA
94534-3802
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-2080
  • Fax:
Mailing address:
  • Phone: 707-416-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number740919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: