Provider Demographics
NPI:1871840280
Name:JACKSON, ANTOINETTE D
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E MAIN ST STE 117
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2365
Mailing Address - Country:US
Mailing Address - Phone:760-255-1496
Mailing Address - Fax:760-255-2542
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2365
Practice Address - Country:US
Practice Address - Phone:760-255-1496
Practice Address - Fax:760-255-2542
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator