Provider Demographics
NPI:1083662845
Name:JACKSON, CHARLES WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
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 1:17122 BEACH BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5992
Mailing Address - Country:US
Mailing Address - Phone:714-847-6545
Mailing Address - Fax:714-847-6547
Practice Address - Street 1:17122 BEACH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5992
Practice Address - Country:US
Practice Address - Phone:714-847-6545
Practice Address - Fax:714-847-6547
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35311208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G353110Medicaid
CAA46305Medicare UPIN
CADF302ZMedicare PIN