Provider Demographics
NPI:1326145756
Name:ANITA C. JACKSON, M.D., INC
Entity Type:Organization
Organization Name:ANITA C. JACKSON, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-694-4688
Mailing Address - Street 1:31720 HIGHWAY 79 SOUTH
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:951-694-4688
Mailing Address - Fax:951-694-4760
Practice Address - Street 1:31720 HIGHWAY 79 SOUTH
Practice Address - Street 2:SUITE 203
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592
Practice Address - Country:US
Practice Address - Phone:951-694-4688
Practice Address - Fax:951-694-4760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053675261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care