Provider Demographics
NPI:1780794107
Name:ACKERMAN, JACK (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3518
Mailing Address - Country:US
Mailing Address - Phone:408-278-3121
Mailing Address - Fax:408-278-3194
Practice Address - Street 1:227 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1603
Practice Address - Country:US
Practice Address - Phone:408-347-2002
Practice Address - Fax:408-347-2189
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6210207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62100Medicaid
CA020A62100Medicare ID - Type Unspecified
CA00AX62100Medicaid