Provider Demographics
NPI:1790781417
Name:JACKSON, MARLENE ESTHER (NP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:ESTHER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:ESTHER
Other - Last Name:CORTEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1695 N SUNRISE WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5572
Mailing Address - Country:US
Mailing Address - Phone:760-778-2210
Mailing Address - Fax:760-778-2214
Practice Address - Street 1:1695 N SUNRISE WAY STE 202
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5572
Practice Address - Country:US
Practice Address - Phone:760-778-2210
Practice Address - Fax:760-778-2214
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP6799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily