Basic Information
Provider Information | |||||||||
NPI: | 1922426998 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | ANNA | ||||||||
MiddleName: | LETICIA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORENO-GALVAN | ||||||||
OtherFirstName: | ANNA | ||||||||
OtherMiddleName: | LETICIA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3626 RUFFIN RD | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585659666 | ||||||||
FaxNumber: | 8585659441 | ||||||||
Practice Location | |||||||||
Address1: | 3626 RUFFIN RD | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585659666 | ||||||||
FaxNumber: | 8585659441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2014 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | A141858 | CA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | A141858 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.