Provider Demographics
NPI:1881989796
Name:JACKSON, DESHA OWANNA (CMA, LVN)
Entity type:Individual
Prefix:
First Name:DESHA
Middle Name:OWANNA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CMA, LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E HILLCREST BLVD STE 519
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2405
Mailing Address - Country:US
Mailing Address - Phone:323-531-4261
Mailing Address - Fax:
Practice Address - Street 1:1520 W 68TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-2021
Practice Address - Country:US
Practice Address - Phone:323-497-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2015-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA258755164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse