MEDICARE: MRS. CAREY LUCILE JACKSON MA

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1992848535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAREY LUCILE JACKSON MA

Provider Business Mailing Address
First Line	:	290 N 10TH ST STE 102
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-3052
Country	:	US
Telephone Number	:	909-825-6188
Fax Number	:	909-872-0652

Provider Business Practice Location Address
First Line	:	290 N 10TH ST STE 102
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-3052
Country	:	US
Telephone Number	:	909-825-6188
Fax Number	:	909-872-0652

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/08/2007

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