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General NPI Number Information
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NPI Number | 1639534993
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Entity Type | Individual
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Provider Name | JESSICA ANNETTE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 12/30/2015
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Last Update Date | 02/20/2020
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Provider Practice Location Address
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Address Line | 4020 CIVIC CENTER DR
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City | SAN RAFAEL
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State | CA
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Zip | 94903-4173
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Country | US
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Telephone | 415-491-2548
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Fax |
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Provider Business Mailing Address
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Address Line | 601 RUSSELL ST
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City | VALLEJO
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State | CA
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Zip | 94591-6543
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Country | US
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Telephone | 415-573-6902
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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 | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number |
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License Number State |
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