Provider Demographics
NPI:1699036756
Name:JACKSON, IVETTE SYRA (APRN-NP)
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:SYRA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:IVETTE
Other - Middle Name:SYRA
Other - Last Name:YAMAMOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-4451
Mailing Address - Fax:310-423-2114
Practice Address - Street 1:8700 BEVERLY BLVD # 4311
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-4451
Practice Address - Fax:310-423-2114
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111345363LN0005X
FLARNP 9350748363LN0005X
CA95007329363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care