Provider Demographics
NPI:1396011755
Name:HARDING-JACKSON, NICHOLAS MAX (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MAX
Last Name:HARDING-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 1:2374 E PACIFICA PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6214
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7040
Practice Address - Street 1:2374 E PACIFICA PL
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220-6214
Practice Address - Country:US
Practice Address - Phone:310-225-3244
Practice Address - Fax:310-698-7040
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60627723207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA146271OtherMEDICAL LICENSE