1871581637 NPI number — JACKSON C FU MD

Table of content: JACKSON C FU MD (NPI 1871581637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871581637 NPI number — JACKSON C FU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FU
Provider First Name:
JACKSON
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1871581637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44241 15TH ST W
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93534-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-948-4691
Provider Business Mailing Address Fax Number:
661-949-5831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44241 15TH ST W
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-948-4691
Provider Business Practice Location Address Fax Number:
661-949-5831
Provider Enumeration Date:
10/06/2005

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: 207V00000X , with the licence number:  A41310 , 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: 00A413100 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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