Healthcare Provider Details

I. General information

NPI: 1366536328
Provider Name (Legal Business Name): PETER J JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 S SIERRA MADRE BLVD
PASADENA CA
91107-5240
US

IV. Provider business mailing address

504 S SIERRA MADRE BLVD
PASADENA CA
91107-5240
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-8811
  • Fax: 626-795-0935
Mailing address:
  • Phone: 626-795-8811
  • Fax: 626-795-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberG46502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: