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General NPI Number Information
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NPI Number | 1386974491
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Entity Type | Organization
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Legal Business Name | JACKSON MEDICAL SUPPLY INC
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Dates
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Enumeration Date | 01/12/2010
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Last Update Date | 06/29/2010
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Provider Practice Location Address
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Address Line | 506 MAIN ST
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City | VACAVILLE
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State | CA
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Zip | 95688-3922
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Country | US
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Telephone | 707-446-7014
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Fax | 707-446-1871
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Provider Business Mailing Address
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Address Line | 506 MAIN ST
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City | VACAVILLE
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State | CA
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Zip | 95688-3922
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Country | US
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Telephone | 707-446-7014
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Fax | 707-446-1871
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Authorized Official
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Title or Position | OWNER
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Name | MS. WENDY ANN WIGMORE
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Credential | RN
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Telephone | 707-446-7014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 103834
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License Number State | CA
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