Provider Demographics
NPI:1033238928
Name:JACKSON, VICTORIA LYNN
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:LYNN
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 1:921 W AVENUE J STE C
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3443
Mailing Address - Country:US
Mailing Address - Phone:661-949-0131
Mailing Address - Fax:661-729-8912
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:661-729-8912
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007473Medicaid
CACBSC9849OtherLA DMH PROVIDER