Provider Demographics
NPI:1902492754
Name:JACKSON, CHRISTIAN DEANTHONY (CTRS)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:DEANTHONY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 W 106TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4438
Mailing Address - Country:US
Mailing Address - Phone:323-867-3923
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHR STE 250
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4270
Practice Address - Country:US
Practice Address - Phone:562-247-0713
Practice Address - Fax:800-985-5002
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83338225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist