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NPI Code Detail

MEDICARE: DR. LENLEY BRADFORD JACKSON M.D.

MEDICARE: DR. LENLEY BRADFORD JACKSON M.D.
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
1207P00000XEmergency Medicine Physician15431HI
2207P00000XEmergency Medicine PhysicianA87877CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00601866OTHERILRAILROAD MEDICARE MEMBER PTAN
2CA2264OTHERILRAILROAD MEDICARE GROUP PTAN
3833120OTHERILMEDICARE GROUP #
5R00965OTHERILMEDICARE INDIVIDUAL #

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1568555845
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LENLEY BRADFORD JACKSON M.D.
Provider Business Mailing Address
First Line : PO BOX 255228
Second Line :
City : SACRAMENTO
State : CA
Zip : 95865-5228
Country : US
Telephone Number : 800-470-0071
Fax Number : 916-854-6769
Provider Business Practice Location Address
First Line : 2505 W HAMMER LN
Second Line :
City : STOCKTON
State : CA
Zip : 95209-2839
Country : US
Telephone Number : 209-954-4040
Fax Number : 209-951-2239
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/01/2006
Last Update Date : 01/12/2026

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