MEDICARE: BRANDON CHRISTOPHER JACKSON IDC

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	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710-1002X	OTHER		IDC

General Provider Information

NPI Number	:	1881030310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON CHRISTOPHER JACKSON IDC

Provider Business Mailing Address
First Line	:	NMCB5
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96601-4961
Country	:	US
Telephone Number	:	619-846-3392
Fax Number	:

Provider Business Practice Location Address
First Line	:	6810 CAMPHOR LN
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139
Country	:	US
Telephone Number	:	619-846-3392
Fax Number	:

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

Provider Enumeration Date	:	05/10/2013
Last Update Date	:	05/10/2013

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