Provider Demographics
NPI:1881830974
Name:JACKSON, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8526 GRAPE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-4134
Mailing Address - Country:US
Mailing Address - Phone:323-586-6401
Mailing Address - Fax:323-586-6482
Practice Address - Street 1:9150 IMPERIAL HWY
Practice Address - Street 2:P-31
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2835
Practice Address - Country:US
Practice Address - Phone:562-940-3694
Practice Address - Fax:562-658-7425
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator