Provider Demographics
NPI:1134496797
Name:JACKSON, KASHMIR A (LVN)
Entity Type:Individual
Prefix:MISS
First Name:KASHMIR
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MRS
Other - First Name:KASHMIR
Other - Middle Name:A
Other - Last Name:JACKSON-MAGNUSSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA217287164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse