Provider Demographics
NPI:1376512145
Name:JACKSON, JUDY M (MD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 N INDIAN CANYON DR
Mailing Address - Street 2:STE E218
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4800
Mailing Address - Country:US
Mailing Address - Phone:760-416-4770
Mailing Address - Fax:866-428-0708
Practice Address - Street 1:1180 N. INDIAN CANYON DR
Practice Address - Street 2:STE E218
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4800
Practice Address - Country:US
Practice Address - Phone:760-416-4770
Practice Address - Fax:760-416-4775
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG797172085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101005Medicare ID - Type Unspecified
E94286Medicare UPIN
CACR699AMedicare PIN