MEDICARE: DR. TYLER PEMBROKE JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	A196288	CA

General Provider Information

NPI Number	:	1295355816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYLER PEMBROKE JACKSON MD

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 16TH ST STE 2100
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-1249
Country	:	US
Telephone Number	:	424-259-6593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	02/02/2026

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