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General NPI Number Information
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NPI Number | 1881989796
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Entity Type | Individual
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Provider Name | DESHA OWANNA JACKSON CMA, LVN
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Gender | Female
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Dates
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Enumeration Date | 06/20/2011
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Last Update Date | 12/27/2015
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Provider Practice Location Address
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Address Line | 1520 W 68TH ST
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City | LOS ANGELES
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State | CA
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Zip | 90047-2021
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Country | US
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Telephone | 323-497-9583
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Fax |
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Provider Business Mailing Address
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Address Line | 309 E HILLCREST BLVD STE 519
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City | INGLEWOOD
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State | CA
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Zip | 90301-2405
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Country | US
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Telephone | 323-531-4261
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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 | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 258755
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License Number State | CA
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