Provider Demographics
NPI:1497225197
Name:JACKSON, TRENT LAMARR
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:LAMARR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22756 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3606
Mailing Address - Country:US
Mailing Address - Phone:818-517-2364
Mailing Address - Fax:
Practice Address - Street 1:22756 HAYNES ST
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-3606
Practice Address - Country:US
Practice Address - Phone:818-517-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1243646347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle