Provider Demographics
NPI:1285850974
Name:JACKSON, ELENA B (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:770 MAGNOLIA AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3122
Mailing Address - Country:US
Mailing Address - Phone:951-736-8144
Mailing Address - Fax:951-736-0701
Practice Address - Street 1:770 MAGNOLIA AVE SUITE 2A
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3122
Practice Address - Country:US
Practice Address - Phone:951-736-8144
Practice Address - Fax:951-736-0701
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA97558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics