Healthcare Provider Details

I. General information

NPI: 1164343869
Provider Name (Legal Business Name): ROBERT C JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 AIRPORT RD
HOOPA CA
95546-0539
US

IV. Provider business mailing address

PO BOX 821
HOOPA CA
95546-0821
US

V. Phone/Fax

Practice location:
  • Phone: 530-625-4261
  • Fax: 530-618-5773
Mailing address:
  • Phone: 530-625-4261
  • Fax: 530-618-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: