1639264864 NPI number — DR. CHRISTIAN STERLING JACKSON M.D.

Table of content: DR. CHRISTIAN STERLING JACKSON M.D. (NPI 1639264864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639264864 NPI number — DR. CHRISTIAN STERLING JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CHRISTIAN
Provider Middle Name:
STERLING
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1639264864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LOMA LINDA VA MEDICAL CENTER 11201 BENTON STREET
Provider Second Line Business Mailing Address:
3A-58/111G
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-825-7084
Provider Business Mailing Address Fax Number:
909-777-3260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LOMA LINDA VA MEDICAL CENTER 11201 BENTON STREET
Provider Second Line Business Practice Location Address:
3A-58/111G
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-825-7084
Provider Business Practice Location Address Fax Number:
909-777-3260
Provider Enumeration Date:
10/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  A101156 , 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: 336-068094 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".