Provider Demographics
NPI:1467010611
Name:JACKSON, CLARA ALEXANDRA
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:ALEXANDRA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 BOXWOOD ST N
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-6626
Mailing Address - Country:US
Mailing Address - Phone:302-233-3923
Mailing Address - Fax:
Practice Address - Street 1:318 BOXWOOD ST N
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-6626
Practice Address - Country:US
Practice Address - Phone:302-233-3923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001269174163W00000X
CA95188546163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse