MEDICARE: DR. FAITH LEE-JACKSON MD

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	207Q00000X	Family Medicine Physician	A63452	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	:	1699745471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAITH LEE-JACKSON MD

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	702-579-3203
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 NORTH WATERMAN AVENUE
Second Line	:
City	:	SAN BERNANDINO
State	:	CA
Zip	:	92404-5105
Country	:	US
Telephone Number	:	909-883-8611
Fax Number	:	909-881-5707

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	11/22/2025

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