Healthcare Provider Details

I. General information

NPI: 1194658484
Provider Name (Legal Business Name): DANIEL JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17875 VON KARMAN AVE STE 150
IRVINE CA
92614-6212
US

IV. Provider business mailing address

17875 VON KARMAN AVE STE 150
IRVINE CA
92614-6212
US

V. Phone/Fax

Practice location:
  • Phone: 949-738-8602
  • Fax: 949-271-2344
Mailing address:
  • Phone: 949-738-8602
  • Fax: 949-271-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: