Provider Demographics
NPI:1497279806
Name:JACKSON, VERNETTA O (RN,BS,CCM)
Entity Type:Individual
Prefix:MS
First Name:VERNETTA
Middle Name:O
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN,BS,CCM
Other - Prefix:
Other - First Name:VAN
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN,BS,CCM
Mailing Address - Street 1:4121 W. 62ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043
Mailing Address - Country:US
Mailing Address - Phone:323-620-0507
Mailing Address - Fax:
Practice Address - Street 1:4121 W 62ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-3612
Practice Address - Country:US
Practice Address - Phone:323-620-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA375590163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management