Provider Demographics
NPI:1619548294
Name:MANN-JACKSON, VICTORIA SOPHIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:SOPHIA
Last Name:MANN-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 1:604 E OCEAN AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6925
Mailing Address - Country:US
Mailing Address - Phone:805-354-9791
Mailing Address - Fax:
Practice Address - Street 1:604 E OCEAN AVE STE A1
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6925
Practice Address - Country:US
Practice Address - Phone:805-737-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program