Individual
JACKSON TEA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MSN, PMHNP-BC
Contact information
Practice address
1720 W BALL RD STE 4C, ANAHEIM, CA 92804-5591
(714) 683-1472
(714) 683-1473
Mailing address
734 LANTANA ST, LA VERNE, CA 91750-5727
(626) 429-0088
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
95033550
CA
Other
Enumeration date
01/22/2025
Last updated
04/15/2025
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