Provider Demographics
NPI:1518435437
Name:JACKSON, VICTORIA LYNN (RN, NP-C, PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, NP-C, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 E MINARETS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0134
Mailing Address - Country:US
Mailing Address - Phone:559-907-7378
Mailing Address - Fax:
Practice Address - Street 1:4860 Y ST STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2309
Practice Address - Country:US
Practice Address - Phone:559-907-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025977163W00000X
CA544793163WC1500X
CAPA56381363A00000X
CA95010493363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant