Healthcare Provider Details

I. General information

NPI: 1124206487
Provider Name (Legal Business Name): BRADLEY A JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E VALENCIA MESA DR
FULLERTON CA
92835-3809
US

IV. Provider business mailing address

300 PASTEUR DR, ROOM H3630, MC: 5642 STANFORD UNIVERSITY MED CTR, DEPT. OF INT. RADIOLOGY
STANFORD CA
94305-5642
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-3978
  • Fax:
Mailing address:
  • Phone: 626-840-4287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA115326
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA115326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: