Provider Demographics
NPI:1700138401
Name:JACKSON, JOSEPH III
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:JACKSON
Suffix:III
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 1:251 E AVENUE K6
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4513
Mailing Address - Country:US
Mailing Address - Phone:661-405-3620
Mailing Address - Fax:661-449-3704
Practice Address - Street 1:251 E AVENUE K6 STE B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4513
Practice Address - Country:US
Practice Address - Phone:661-405-3620
Practice Address - Fax:661-449-3704
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes172V00000XOther Service ProvidersCommunity Health Worker