=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770308447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONI LYNN JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 MAINE ST APT R1
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-470-8212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 E 18TH ST OFC
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-867-1416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------