Provider Demographics
NPI:1417727595
Name:JACKSON, CARRIE (CA-CPT1)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CA-CPT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 INLAND EMPIRE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5577
Mailing Address - Country:US
Mailing Address - Phone:909-870-0442
Mailing Address - Fax:
Practice Address - Street 1:3400 INLAND EMPIRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5577
Practice Address - Country:US
Practice Address - Phone:909-870-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT00064512246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy