Provider Demographics
NPI:1770308447
Name:JACKSON, TONI LYNN
Entity type:Individual
Prefix:
First Name:TONI
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 1:515 E 18TH ST OFC
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2743
Mailing Address - Country:US
Mailing Address - Phone:510-867-1416
Mailing Address - Fax:
Practice Address - Street 1:201 MAINE ST APT R1
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5851
Practice Address - Country:US
Practice Address - Phone:925-470-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker