Basic Information
| Provider Information | |||||||||
| NPI: | 1871840280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 222 E MAIN ST STE 117 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 E MAIN ST STE 117 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.