Healthcare Provider Details

I. General information

NPI: 1134574528
Provider Name (Legal Business Name): CAMILLE JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST DEPARTMENT OF SURGERY
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

513 PARNASSUS AVE, S321 DEPARTMENT OF SURGERY
SAN FRANCISCO CA
94143-2205
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-4965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA156408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: