Provider Demographics
NPI:1326672494
Name:JACKSON, PHYLISS L (LCMT,HE)
Entity Type:Individual
Prefix:
First Name:PHYLISS
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCMT,HE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 ARENA BLVD APT 7106
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-7940
Mailing Address - Country:US
Mailing Address - Phone:916-706-9892
Mailing Address - Fax:
Practice Address - Street 1:1 ADVENTIST HEALTH WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3266
Practice Address - Country:US
Practice Address - Phone:916-406-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80744225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4915041Medicaid