Healthcare Provider Details

I. General information

NPI: 1720317175
Provider Name (Legal Business Name): RICHARD JOSEPH JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CHARLES E YOUNG DR S EHS SPH UCLA BOX 56-070
LOS ANGELES CA
90095-1772
US

IV. Provider business mailing address

650 CHARLES E YOUNG DR S EHS SPH UCLA BOX 56-070
LOS ANGELES CA
90095-1772
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-8522
  • Fax: 310-794-2106
Mailing address:
  • Phone: 310-206-8522
  • Fax: 310-794-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG34076
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberG34076
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: