Healthcare Provider Details

I. General information

NPI: 1356250864
Provider Name (Legal Business Name): JULIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15373 INNOVATION DR STE 220
SAN DIEGO CA
92128-3425
US

IV. Provider business mailing address

3351 APACHE AVE
SAN DIEGO CA
92117-6204
US

V. Phone/Fax

Practice location:
  • Phone: 858-592-8855
  • Fax:
Mailing address:
  • Phone: 818-288-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: