MEDICARE: CHARLES W JACKSON MD INC

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	208D00000X	General Practice Physician	G35311	CA

General Provider Information

NPI Number	:	1851594006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES W JACKSON MD INC

Provider Business Mailing Address
First Line	:	PO BOX 7630
Second Line	:
City	:	LAGUNA NIGUEL
State	:	CA
Zip	:	92607-7630
Country	:	US
Telephone Number	:	949-643-3345
Fax Number	:	949-643-3560

Provider Business Practice Location Address
First Line	:	17122 BEACH BLVD
Second Line	:	STE. 102
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-5992
Country	:	US
Telephone Number	:	714-847-6545
Fax Number	:	714-847-6547

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES JACKSON
Credential	:	M.D.
Telephone Number	:	714-847-6545

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/28/2010

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