Provider Demographics
NPI:1962377457
Name:JACKSON, BRETT COLE
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:COLE
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 1:1329 FIGUEROA PL APT 9-12
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2335
Mailing Address - Country:US
Mailing Address - Phone:562-449-7730
Mailing Address - Fax:
Practice Address - Street 1:1329 FIGUEROA PL APT 9-12
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2335
Practice Address - Country:US
Practice Address - Phone:562-449-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide