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General NPI Number Information
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NPI Number | 1811906316
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Entity Type | Individual
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Provider Name | AMANDA SUE JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 850 5TH ST
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City | GONZALES
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State | CA
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Zip | 93926-9491
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Country | US
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Telephone | 831-675-3601
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Fax |
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Provider Business Mailing Address
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Address Line | 100 WILSON RD STE 100
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City | MONTEREY
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State | CA
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Zip | 93940-7885
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Country | US
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Telephone | 831-242-8301
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A91439
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 77092-20
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 2080C0008X
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Taxonomy Name | Child Abuse Pediatrics Physician
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License Number | 77092-20
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License Number State | WI
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