Healthcare Provider Details

I. General information

NPI: 1033128434
Provider Name (Legal Business Name): JACKSON MICHAEL ROWLAND M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 EMELINE AVE
SANTA CRUZ CA
95060-1976
US

IV. Provider business mailing address

1400 EMELINE AVE
SANTA CRUZ CA
95060-1976
US

V. Phone/Fax

Practice location:
  • Phone: 831-454-4971
  • Fax: 831-454-4663
Mailing address:
  • Phone: 831-454-4170
  • Fax: 831-454-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA71024
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA71024
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA71024
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA71024
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA71024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: