Provider Demographics
NPI:1235126475
Name:JACKSON, HAROLD WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:WILLIAM
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4646 BROCKTON AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0104
Mailing Address - Country:US
Mailing Address - Phone:951-774-2800
Mailing Address - Fax:951-774-2846
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-774-2942
Practice Address - Fax:951-774-2945
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A3741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E08695Medicare ID - Type Unspecified