Provider Demographics
NPI:1174760961
Name:JACKSON, ANISHA NICOLE (PA)
Entity type:Individual
Prefix:MS
First Name:ANISHA
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 TENNESSEE ST STE C
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8161
Mailing Address - Country:US
Mailing Address - Phone:217-416-2021
Mailing Address - Fax:217-569-4332
Practice Address - Street 1:2573 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545
Practice Address - Country:US
Practice Address - Phone:951-658-7289
Practice Address - Fax:951-756-5004
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2025-06-12
Deactivation Date:2019-08-14
Deactivation Code:
Reactivation Date:2019-09-30
Provider Licenses
StateLicense IDTaxonomies
CA56906405300000X, 363A00000X
IL085-003405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174760961Medicaid
CA56906OtherSTATE CA LICENSE