Provider Demographics
NPI:1497297154
Name:JACKSON, TOMMY
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
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 1:1760 TERMINO AVE
Mailing Address - Street 2:208
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2105
Mailing Address - Country:US
Mailing Address - Phone:562-961-5655
Mailing Address - Fax:562-961-8836
Practice Address - Street 1:1760 TERMINO AVE
Practice Address - Street 2:208
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2105
Practice Address - Country:US
Practice Address - Phone:562-961-5655
Practice Address - Fax:562-961-8836
Is Sole Proprietor?:No
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02-0922246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA02-0922OtherNATIONAL BOARD FOR CERTIFICATION OF ORTHOPAEDIC TECHNOLOGISTS