Provider Demographics
NPI:1508622150
Name:JACKSON, JEANNE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 SANTIAGO CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0203
Mailing Address - Country:US
Mailing Address - Phone:909-582-5140
Mailing Address - Fax:
Practice Address - Street 1:3734 SANTIAGO CREEK WAY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-0203
Practice Address - Country:US
Practice Address - Phone:909-582-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA705082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner