Provider Demographics
NPI:1275656027
Name:JACKSON, RHONDA
Entity Type:Individual
Prefix:
First Name:RHONDA
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:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366
Mailing Address - Country:US
Mailing Address - Phone:760-572-4100
Mailing Address - Fax:760-572-2133
Practice Address - Street 1:401 PICACHO ROAD
Practice Address - Street 2:
Practice Address - City:WINTERHAVEN
Practice Address - State:CA
Practice Address - Zip Code:92283
Practice Address - Country:US
Practice Address - Phone:760-572-4100
Practice Address - Fax:760-572-2133
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513816163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse