Provider Demographics
NPI:1861997298
Name:JACKSON, CANDACE LYNN (MD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9434 MEDICAL CENTER DR # MC7411
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1337
Mailing Address - Country:US
Mailing Address - Phone:858-657-8530
Mailing Address - Fax:
Practice Address - Street 1:9434 MEDICAL CENTER DR # MC7411
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1337
Practice Address - Country:US
Practice Address - Phone:858-657-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65863207R00000X
MN29157207R00000X
CAA173379207RC0000X
NY326893207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine