MEDICARE: MRS. JANETTE LEE JACKSON PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant	16118	CA

General Provider Information

NPI Number	:	1639390578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANETTE LEE JACKSON PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	665 N D ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92401-1109
Country	:	US
Telephone Number	:	909-708-8158
Fax Number	:	909-380-7030

Provider Business Practice Location Address
First Line	:	2618 SOUTH WESTERN AVENUE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018
Country	:	US
Telephone Number	:	323-730-9000
Fax Number	:	323-730-4825

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	10/15/2019

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