MEDICARE: DR. GAIL N JACKSON M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	G41783	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063401958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GAIL N JACKSON M.D

Provider Business Mailing Address
First Line	:	8635 W 3RD ST
Second Line	:	SUITE 680 WEST
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-6101
Country	:	US
Telephone Number	:	310-659-2666
Fax Number	:

Provider Business Practice Location Address
First Line	:	8635 W 3RD ST
Second Line	:	SUITE 680 WEST
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-6101
Country	:	US
Telephone Number	:	310-659-2666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	07/08/2007

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