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NPI Code Detail

MEDICARE: MS. CHARLRE-L E JACKSON AA

MEDICARE: MS. CHARLRE-L E JACKSON AA
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
1171M00000XCase Manager/Care Coordinator

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1356590749
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CHARLRE-L E JACKSON AA
Provider Business Mailing Address
First Line : 1453 16TH ST
Second Line :
City : SANTA MONICA
State : CA
Zip : 90404-2715
Country : US
Telephone Number : 310-450-4050
Fax Number : 310-450-7309
Provider Business Practice Location Address
First Line : 1453 16TH ST
Second Line :
City : SANTA MONICA
State : CA
Zip : 90404-2715
Country : US
Telephone Number : 310-450-4050
Fax Number : 310-450-7309
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/10/2008
Last Update Date : 05/01/2017

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