Healthcare Provider Details

I. General information

NPI: 1760238562
Provider Name (Legal Business Name): TIFFANY JACKSON HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27699 JEFFERSON AVE STE 301
TEMECULA CA
92590-2661
US

IV. Provider business mailing address

27699 JEFFERSON AVE STE 301
TEMECULA CA
92590-2661
US

V. Phone/Fax

Practice location:
  • Phone: 951-676-5225
  • Fax: 951-676-5285
Mailing address:
  • Phone: 951-676-5225
  • Fax: 951-676-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number8973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: