Provider Demographics
NPI:1447827167
Name:CHRISTA L JACKSON DENTAL HYGIENIST, INC.
Entity type:Organization
Organization Name:CHRISTA L JACKSON DENTAL HYGIENIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDHAP
Authorized Official - Phone:818-269-8898
Mailing Address - Street 1:4508 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1209
Mailing Address - Country:US
Mailing Address - Phone:818-269-8898
Mailing Address - Fax:818-506-2595
Practice Address - Street 1:4508 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-1209
Practice Address - Country:US
Practice Address - Phone:818-269-8898
Practice Address - Fax:818-506-2595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA128592243Medicaid