Healthcare Provider Details

I. General information

NPI: 1093023509
Provider Name (Legal Business Name): MICHELLE JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5434 OLIVE ST UNIT A
SAN DIEGO CA
92105-5054
US

IV. Provider business mailing address

5434 OLIVE ST UNIT A
SAN DIEGO CA
92105-5054
US

V. Phone/Fax

Practice location:
  • Phone: 619-840-9440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21621
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: