Provider Demographics
NPI:1255174769
Name:JACKSON, JOSHUA ROBERT (APRN)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ROBERT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3956 LAVINE WAY UNIT 104
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-3651
Mailing Address - Country:US
Mailing Address - Phone:352-286-9333
Mailing Address - Fax:
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-378-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily