Basic Information
| Provider Information | |||||||||
| NPI: | 1699847913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | ORIO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26577 CORTE EMPRESA | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515876065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41715 WINCHESTER RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925904808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517191414 | ||||||||
| FaxNumber: | 9517193158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13164 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN288619 | 05 | CA | MEDICAID |