Healthcare Provider Details

I. General information

NPI: 1902492754
Provider Name (Legal Business Name): CHRISTIAN DEANTHONY JACKSON CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 GOLDEN SHR STE 250
LONG BEACH CA
90802-4270
US

IV. Provider business mailing address

818 W 106TH ST
LOS ANGELES CA
90044-4438
US

V. Phone/Fax

Practice location:
  • Phone: 562-247-0713
  • Fax: 800-985-5002
Mailing address:
  • Phone: 323-867-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number83338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: