Provider Demographics
NPI:1053029017
Name:JACKSON, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 N PALM AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5510
Mailing Address - Country:US
Mailing Address - Phone:866-981-0656
Mailing Address - Fax:866-571-5484
Practice Address - Street 1:8050 N PALM AVE STE 300
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5510
Practice Address - Country:US
Practice Address - Phone:866-981-0656
Practice Address - Fax:866-571-5484
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator