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General NPI Number Information
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NPI Number | 1588557219
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Entity Type | Individual
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Provider Name | CEDRIC JACKSON FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 06/02/2025
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Last Update Date | 09/08/2025
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Provider Practice Location Address
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Address Line | 404 CAMINO DEL RIO S STE 102
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City | SAN DIEGO
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State | CA
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Zip | 92108-3586
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Country | US
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Telephone | 800-316-6314
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Fax |
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Provider Business Mailing Address
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Address Line | 404 CAMINO DEL RIO S STE 102
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City | SAN DIEGO
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State | CA
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Zip | 92108-3586
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Country | US
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Telephone |
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1208385
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License Number State | TX
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