Provider Demographics
NPI:1114929437
Name:JACKSON MEDICAL SERVICES
Entity Type:Organization
Organization Name:JACKSON MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-222-1075
Mailing Address - Street 1:2930B HILLTOP MALL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1902
Mailing Address - Country:US
Mailing Address - Phone:510-222-1075
Mailing Address - Fax:510-222-1575
Practice Address - Street 1:2930B HILLTOP MALL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1902
Practice Address - Country:US
Practice Address - Phone:510-222-1075
Practice Address - Fax:510-222-1575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADME02720F332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02720FMedicaid
CADME02720FMedicaid