Healthcare Provider Details

I. General information

NPI: 1689105223
Provider Name (Legal Business Name): SAMUEL BARRETT JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 TROUSDALE DR
BURLINGAME CA
94010-4506
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8600
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA163124
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA163124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: