Healthcare Provider Details

I. General information

NPI: 1851594006
Provider Name (Legal Business Name): CHARLES W JACKSON MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17122 BEACH BLVD STE. 102
HUNTINGTON BEACH CA
92647-5992
US

IV. Provider business mailing address

PO BOX 7630
LAGUNA NIGUEL CA
92607-7630
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-6545
  • Fax: 714-847-6547
Mailing address:
  • Phone: 949-643-3345
  • Fax: 949-643-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG35311
License Number StateCA

VIII. Authorized Official

Name: DR. CHARLES JACKSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-847-6545