Healthcare Provider Details

I. General information

NPI: 1760274831
Provider Name (Legal Business Name): LA PORSCHE MICHELLE JACKSON M.ED/CI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10672 PENDLETON ST
RIVERSIDE CA
92505-1740
US

IV. Provider business mailing address

22890 PAHUTE DR
MORENO VALLEY CA
92553-6427
US

V. Phone/Fax

Practice location:
  • Phone: 310-912-5168
  • Fax:
Mailing address:
  • Phone: 310-912-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: