Healthcare Provider Details

I. General information

NPI: 1124072087
Provider Name (Legal Business Name): BRUCE L JACKSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15863 KASOTA RD
APPLE VALLEY CA
92307-4507
US

IV. Provider business mailing address

11919 HESPERIA RD
HESPERIA CA
92345-1855
US

V. Phone/Fax

Practice location:
  • Phone: 760-948-1454
  • Fax: 760-948-6100
Mailing address:
  • Phone: 760-948-1454
  • Fax: 760-948-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: