Healthcare Provider Details

I. General information

NPI: 1275656027
Provider Name (Legal Business Name): RHONDA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PICACHO ROAD
WINTERHAVEN CA
92283
US

IV. Provider business mailing address

PO BOX 1368
YUMA AZ
85366
US

V. Phone/Fax

Practice location:
  • Phone: 760-572-4100
  • Fax: 760-572-2133
Mailing address:
  • Phone: 760-572-4100
  • Fax: 760-572-2133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number513816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: