Healthcare Provider Details

I. General information

NPI: 1548764830
Provider Name (Legal Business Name): BIANCA VALERIA CARRION-JACKSON MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTH STATE STREET, CTA7D,
LOS ANGELES CA
90033
US

IV. Provider business mailing address

1200 NORTH STATE STREET, CTA7D,
LOS ANGELES CA
90033
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-5707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA164597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: