Provider Demographics
NPI:1073594727
Name:LIM, JACKSON M (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:M
Last Name:LIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1531 PLUMAS CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2960
Mailing Address - Country:US
Mailing Address - Phone:530-674-9737
Mailing Address - Fax:530-674-9734
Practice Address - Street 1:1531 PLUMAS CT
Practice Address - Street 2:SUITE A
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-2960
Practice Address - Country:US
Practice Address - Phone:530-674-9737
Practice Address - Fax:530-674-9734
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAE4263213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E42630Medicaid
U80575Medicare UPIN
000E42631Medicare ID - Type Unspecified
CA000E42630Medicaid