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General NPI Number Information
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NPI Number | 1174760961
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Entity Type | Individual
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Provider Name | ANISHA NICOLE JACKSON PA
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Gender | Female
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Dates
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Enumeration Date | 01/15/2009
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Last Update Date | 10/04/2025
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Provider Practice Location Address
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Address Line | 5 HUTTON CENTRE DR STE 950
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City | SANTA ANA
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State | CA
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Zip | 92707-8744
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Country | US
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Telephone | 855-434-7763
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Fax |
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Provider Business Mailing Address
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Address Line | 461 TENNESSEE ST STE C
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City | REDLANDS
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State | CA
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Zip | 92373-8161
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Country | US
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Telephone | 217-416-2021
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Fax | 217-569-4332
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 56906
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | 56906
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License Number State | CA
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