Healthcare Provider Details

I. General information

NPI: 1497297154
Provider Name (Legal Business Name): TOMMY JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2016
Last Update Date: 11/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 TERMINO AVE 208
LONG BEACH CA
90804-2105
US

IV. Provider business mailing address

1760 TERMINO AVE 208
LONG BEACH CA
90804-2105
US

V. Phone/Fax

Practice location:
  • Phone: 562-961-5655
  • Fax: 562-961-8836
Mailing address:
  • Phone: 562-961-5655
  • Fax: 562-961-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number02-0922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: