Provider Demographics
NPI:1134331259
Name:JACKSON, COLLEEN DELORES (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:DELORES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:849 MANZANITA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-2961
Mailing Address - Country:US
Mailing Address - Phone:310-423-8572
Mailing Address - Fax:310-423-8550
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:THALIANS 2W, RM 218
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-8572
Practice Address - Fax:310-423-8550
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA12835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily