Provider Demographics
NPI:1346229382
Name:JACKSON, BRENT CLARENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:CLARENCE
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64902208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A649020OtherBLUE SHIELD OF CA
CA00A649020Medicaid
113712291OtherBLUE CROSS OF CA
113712291 92123 0000OtherWPS TRICARE
113712291OtherBLUE CROSS OF CA
CA00A649020OtherBLUE SHIELD OF CA