Provider Demographics
NPI:1043296882
Name:JACKSON, MARY TALLMADGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TALLMADGE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:120 CORBETT CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-5151
Mailing Address - Country:US
Mailing Address - Phone:805-474-8518
Mailing Address - Fax:805-474-8555
Practice Address - Street 1:120 CORBETT CANYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-5151
Practice Address - Country:US
Practice Address - Phone:805-459-0529
Practice Address - Fax:805-474-8555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2016-02-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG56252207V00000X
HI6198207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology