Healthcare Provider Details

I. General information

NPI: 1235126475
Provider Name (Legal Business Name): HAROLD WILLIAM JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 BROCKTON AVE SUITE 202
RIVERSIDE CA
92506-0102
US

IV. Provider business mailing address

4646 BROCKTON AVE STE 203
RIVERSIDE CA
92506-0104
US

V. Phone/Fax

Practice location:
  • Phone: 951-774-2942
  • Fax: 951-774-2945
Mailing address:
  • Phone: 951-774-2800
  • Fax: 951-774-2846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A3741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: