MEDICARE: MS. MICHELLE JACKSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	21621	CA
2	363L00000X	Nurse Practitioner	21621	CA

General Provider Information

NPI Number	:	1093023509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE JACKSON NP

Provider Business Mailing Address
First Line	:	5434 OLIVE ST UNIT A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-5054
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5434 OLIVE ST UNIT A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-5054
Country	:	US
Telephone Number	:	619-840-9440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2010
Last Update Date	:	04/07/2026

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