Healthcare Provider Details

I. General information

NPI: 1376071092
Provider Name (Legal Business Name): LINDA CHINYERE JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

IV. Provider business mailing address

200 OCEANGATE STE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-3026
  • Fax: 909-335-3167
Mailing address:
  • Phone: 562-499-6191
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95006662
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: