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General NPI Number Information
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NPI Number | 1679994263
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Entity Type | Individual
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Provider Name | MIKEL JAMES JACKSON ATC
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Gender | Male
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Dates
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Enumeration Date | 12/26/2013
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Last Update Date | 12/26/2013
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Provider Practice Location Address
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Address Line | 1832 101ST AVE
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City | OAKLAND
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State | CA
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Zip | 94603-3304
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Country | US
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Telephone | 408-799-1230
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 761
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City | SAN LEANDRO
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State | CA
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Zip | 94577-0435
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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