Provider Demographics
NPI:1023003605
Name:JACKSON, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:504
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
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
Practice Address - Street 2:504
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-588-5800
Practice Address - Fax:949-380-3344
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA71112207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH18175Medicare UPIN