1184734196 NPI number — GAIL N JACKSON MD PC

Table of content: (NPI 1184734196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184734196 NPI number — GAIL N JACKSON MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAIL N JACKSON MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184734196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11692
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90295-7692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-451-2300
Provider Business Mailing Address Fax Number:
310-451-2325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 OCEAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90401-1023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-451-2300
Provider Business Practice Location Address Fax Number:
310-451-2325
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
310-659-2666

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  G41783 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ET547A . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com