Healthcare Provider Details

I. General information

NPI: 1215099254
Provider Name (Legal Business Name): TIMOTHY JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR FLEET LIAISON BLDG 2
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR FLEET LIAISON BLDG 2
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-9512
  • Fax: 619-532-6404
Mailing address:
  • Phone: 619-532-9512
  • Fax: 619-532-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: