Provider Demographics
NPI:1184852592
Name:JACKSON, GAYLA ESTELLE (MD)
Entity Type:Individual
Prefix:
First Name:GAYLA
Middle Name:ESTELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GAYLA
Other - Middle Name:
Other - Last Name:GUESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD STE 109N
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6148
Mailing Address - Country:US
Mailing Address - Phone:314-953-6968
Mailing Address - Fax:314-953-6960
Practice Address - Street 1:11155 DUNN RD STE 109N
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6148
Practice Address - Country:US
Practice Address - Phone:314-953-6968
Practice Address - Fax:314-953-6960
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012019250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine