Basic Information
Provider Information
NPI: 1366883696
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: EMILY
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 52754
Address2:  
City: IRVINE
State: CA
PostalCode: 926192754
CountryCode: US
TelephoneNumber: 9493385660
FaxNumber:  
Practice Location
Address1: 30300 CAMINO CAPISTRANO
Address2:  
City: SAN JUAN CAPISTRANO
State: CA
PostalCode: 926751304
CountryCode: US
TelephoneNumber: 9492402030
FaxNumber: 9494297627
Other Information
ProviderEnumerationDate: 07/15/2013
LastUpdateDate: 07/15/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X62206CAY Dental ProvidersDentist 

No ID Information.


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