Healthcare Provider Details

I. General information

NPI: 1235101346
Provider Name (Legal Business Name): MINAL DAMANI JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 03/05/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CT
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

8080 PARKWAY DR LA MESA MEDICAL OFFICES
LA MESA CA
91942-2104
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-4062
  • Fax: 760-719-4061
Mailing address:
  • Phone: 619-589-3403
  • Fax: 619-589-3432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA111952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: