Healthcare Provider Details

I. General information

NPI: 1730167917
Provider Name (Legal Business Name): MR. CHARLES F JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DRIVE NAVAL MEDICAL CENTER, SAN DIEGO
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

6320 LAKE ATHABASKA PL
SAN DIEGO CA
92119-3527
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4904
  • Fax:
Mailing address:
  • Phone: 619-465-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAT-001058-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: