Provider Demographics
NPI:1861059784
Name:JACKSON, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 MAGNOLIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3331
Mailing Address - Country:US
Mailing Address - Phone:951-735-6060
Mailing Address - Fax:
Practice Address - Street 1:341 MAGNOLIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3331
Practice Address - Country:US
Practice Address - Phone:951-735-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861059784OtherNPI