Provider Demographics
NPI:1043945157
Name:JACKSON, MAIDA ELENA (FNP)
Entity Type:Individual
Prefix:
First Name:MAIDA
Middle Name:ELENA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MAIDA
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6137 E DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-8937
Mailing Address - Country:US
Mailing Address - Phone:559-473-7943
Mailing Address - Fax:
Practice Address - Street 1:3612 1/2 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2326
Practice Address - Country:US
Practice Address - Phone:323-264-7796
Practice Address - Fax:323-264-7778
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily