Provider Demographics
NPI:1912198185
Name:JACKSON, WELDON KARL (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:KARL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28125 BRADLEY RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2248
Mailing Address - Country:US
Mailing Address - Phone:951-679-8751
Mailing Address - Fax:951-679-8751
Practice Address - Street 1:28125 BRADLEY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2248
Practice Address - Country:US
Practice Address - Phone:951-679-8751
Practice Address - Fax:951-679-8751
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 1237231H00000X
CAHA 1750237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4A 1750Medicaid
CAZZZ28350ZMedicare UPIN