Provider Demographics
NPI:1760656904
Name:JACKSON, PATRICIA LYNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LYNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4754 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-5253
Mailing Address - Country:US
Mailing Address - Phone:619-990-2878
Mailing Address - Fax:
Practice Address - Street 1:4754 PALM AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5253
Practice Address - Country:US
Practice Address - Phone:619-990-2878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7976171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist