Provider Demographics
NPI:1629194972
Name:JACKSON, JENIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 COLONIAL VLG APT 3
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9540
Mailing Address - Country:US
Mailing Address - Phone:530-368-3357
Mailing Address - Fax:
Practice Address - Street 1:34248 E. TOWLE RD
Practice Address - Street 2:
Practice Address - City:ALTA
Practice Address - State:CA
Practice Address - Zip Code:95701
Practice Address - Country:US
Practice Address - Phone:530-389-9208
Practice Address - Fax:530-389-9209
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist