Provider Demographics
NPI:1306007059
Name:JACKSON, CURTIS
Entity Type:Individual
Prefix:MS
First Name:CURTIS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 E WORKMAN AVE # 143
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1604
Mailing Address - Country:US
Mailing Address - Phone:626-736-3537
Mailing Address - Fax:
Practice Address - Street 1:1411 N GRAND AVE
Practice Address - Street 2:110
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1001
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner