Provider Demographics
NPI:1538190830
Name:ROBERT J JACKSON M.D., INC.
Entity type:Organization
Organization Name:ROBERT J JACKSON M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-588-5800
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 405
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3683
Mailing Address - Country:US
Mailing Address - Phone:949-588-5800
Mailing Address - Fax:949-380-3344
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 405
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3683
Practice Address - Country:US
Practice Address - Phone:949-588-5800
Practice Address - Fax:949-380-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71112207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5315380001Medicare NSC