Provider Demographics
NPI:1376275115
Name:JACKSON, DAVID D (EMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 CHERRY TREE DR
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-8845
Mailing Address - Country:US
Mailing Address - Phone:559-826-8404
Mailing Address - Fax:
Practice Address - Street 1:2655 CHERRY TREE DR
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-8845
Practice Address - Country:US
Practice Address - Phone:559-826-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3390030146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic