Provider Demographics
NPI:1659649275
Name:JACKSON, KAREN LYNN
Entity Type:Individual
Prefix:MRS
First Name:KAREN
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 1:364 PLOVER PL
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-1905
Mailing Address - Country:US
Mailing Address - Phone:210-685-1113
Mailing Address - Fax:
Practice Address - Street 1:2675 APPIAN WAY
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2202
Practice Address - Country:US
Practice Address - Phone:510-222-8403
Practice Address - Fax:510-222-8277
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA698773163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA698773OtherCALIFORNIA BOARD OF REGISTERED NURSES