Healthcare Provider Details

I. General information

NPI: 1235570441
Provider Name (Legal Business Name): MS. SHARON BRAZIL JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 E 3RD ST STE C
LOS ANGELES CA
90013-1630
US

IV. Provider business mailing address

470 E 3RD ST STE C
LOS ANGELES CA
90013-1630
US

V. Phone/Fax

Practice location:
  • Phone: 213-620-5712
  • Fax: 213-621-4155
Mailing address:
  • Phone: 213-620-5712
  • Fax: 213-621-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: