Provider Demographics
NPI:1639534993
Name:JACKSON, JESSICA ANNETTE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNETTE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6543
Mailing Address - Country:US
Mailing Address - Phone:415-573-6902
Mailing Address - Fax:
Practice Address - Street 1:4020 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4173
Practice Address - Country:US
Practice Address - Phone:415-491-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD3589691Medicaid