Provider Demographics
NPI:1699847913
Name:JACKSON, MARILYN ORIO (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:ORIO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26577 CORTE EMPRESA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590
Mailing Address - Country:US
Mailing Address - Phone:951-587-6065
Mailing Address - Fax:
Practice Address - Street 1:41715 WINCHESTER RD
Practice Address - Street 2:SUITE 204
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4808
Practice Address - Country:US
Practice Address - Phone:951-719-1414
Practice Address - Fax:951-719-3158
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN288619Medicaid
CAZZZ32057ZMedicare ID - Type UnspecifiedPPIN
CAZZZ32057ZMedicare PIN
CARN288619Medicaid