Provider Demographics
NPI:1851865034
Name:JACKSON, ROBERT TERRELL (DIABETES LS COACH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TERRELL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DIABETES LS COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-0821
Mailing Address - Country:US
Mailing Address - Phone:951-642-0341
Mailing Address - Fax:951-736-6401
Practice Address - Street 1:650 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3417
Practice Address - Country:US
Practice Address - Phone:951-642-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558583427OtherRD,CDE IN THE PROCESS OF REAPPLYING FOR MEDICARE