Healthcare Provider Details

I. General information

NPI: 1992577043
Provider Name (Legal Business Name): SYLVIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 CHICAGO AVE STE A13
RIVERSIDE CA
92507-2316
US

IV. Provider business mailing address

4474 KRISTEN CT
RIVERSIDE CA
92501-1781
US

V. Phone/Fax

Practice location:
  • Phone: 951-823-0175
  • Fax:
Mailing address:
  • Phone: 951-310-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: