Provider Demographics
NPI:1639390578
Name:JACKSON, JANETTE LEE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:JANETTE
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:665 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1109
Mailing Address - Country:US
Mailing Address - Phone:909-708-8158
Mailing Address - Fax:909-380-7030
Practice Address - Street 1:2618 SOUTH WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018
Practice Address - Country:US
Practice Address - Phone:323-730-9000
Practice Address - Fax:323-730-4825
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant