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General NPI Number Information
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NPI Number | 1659460814
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Entity Type | Individual
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Provider Name | GRACE ELIZABETH JACKSON MD
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Gender | Female
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 4441 E CESAR CHAVEZ BLVD
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City | FRESNO
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State | CA
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Zip | 93702-3604
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Country | US
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Telephone | 559-600-9059
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Fax |
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Provider Business Mailing Address
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Address Line | 2160 S 1ST AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-3328
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Country | US
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Telephone | 708-216-9000
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 30325
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 15320
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | D0090940
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License Number State | MD
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 12228A
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License Number State | WY
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Taxonomy #5
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | C56001
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 200200922
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License Number State | NC
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Taxonomy #7
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD-17101
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License Number State | HI
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Taxonomy #8
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 46710
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License Number State | AZ
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Taxonomy #9
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 63217
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License Number State | TN
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Taxonomy #10
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036154094
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License Number State | IL
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