Provider Demographics
NPI:1629605746
Name:JACKSON, RENAE
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:
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 1:25460 MEDICAL CENTER DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-677-4748
Mailing Address - Fax:
Practice Address - Street 1:25460 MEDICAL CENTER DRIVE, SUITE 100
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-677-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA193442207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology