Provider Demographics
NPI:1730167917
Name:JACKSON, CHARLES F
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 LAKE ATHABASKA PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3527
Mailing Address - Country:US
Mailing Address - Phone:619-465-4621
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DRIVE
Practice Address - Street 2:NAVAL MEDICAL CENTER, SAN DIEGO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-524-4904
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT-001058-L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist