Provider Demographics
NPI:1235265513
Name:JACKSON, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ST PAUL AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2038
Mailing Address - Country:US
Mailing Address - Phone:213-482-6400
Mailing Address - Fax:
Practice Address - Street 1:1111 W 6TH ST
Practice Address - Street 2:SUITE # 111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1800
Practice Address - Country:US
Practice Address - Phone:213-482-6400
Practice Address - Fax:213-482-6408
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265520183Medicaid
CA1306922554Medicaid
CA1841342318Medicaid