Healthcare Provider Details

I. General information

NPI: 1255809372
Provider Name (Legal Business Name): EMMA J JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33048 CANOPY LN
LAKE ELSINORE CA
92532-2535
US

IV. Provider business mailing address

33048 CANOPY LN
LAKE ELSINORE CA
92532-2535
US

V. Phone/Fax

Practice location:
  • Phone: 909-614-3039
  • Fax:
Mailing address:
  • Phone: 909-614-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95042368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP950147
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number95042368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: