Provider Demographics
NPI:1366645897
Name:JACKSON, LA'SHAWNTA (PA)
Entity Type:Individual
Prefix:MRS
First Name:LA'SHAWNTA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16130 GRANDE ISLA CIR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1621
Mailing Address - Country:US
Mailing Address - Phone:951-301-7611
Mailing Address - Fax:951-301-7616
Practice Address - Street 1:26960 CHERRY HILLS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2512
Practice Address - Country:US
Practice Address - Phone:951-301-7615
Practice Address - Fax:951-301-7616
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant