Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003437922 |
---|---|
Provider Name | Fatima Jackson |
First Address | Los Angeles, CA 90041-1744 |
Second Address | Pasadena, CA 91105-2711 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2020 |
Last Update Date | 01/05/2020 |