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General NPI Number Information
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NPI Number | 1043296882
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Entity Type | Individual
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Provider Name | MARY TALLMADGE JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 12/22/2005
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Last Update Date | 02/16/2016
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Provider Practice Location Address
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Address Line | 120 CORBETT CANYON RD
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City | ARROYO GRANDE
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State | CA
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Zip | 93420-5151
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Country | US
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Telephone | 805-459-0529
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Fax | 805-474-8555
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Provider Business Mailing Address
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Address Line | 120 CORBETT CANYON RD
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City | ARROYO GRANDE
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State | CA
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Zip | 93420-5151
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Country | US
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Telephone | 805-474-8518
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Fax | 805-474-8555
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | G56252
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 6198
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License Number State | HI
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