Provider Demographics
NPI:1427017151
Name:JACKSON, THOMAS MORTON (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MORTON
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 26060
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729
Mailing Address - Country:US
Mailing Address - Phone:559-455-4000
Mailing Address - Fax:559-455-4004
Practice Address - Street 1:3700 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118
Practice Address - Country:US
Practice Address - Phone:415-600-2200
Practice Address - Fax:415-750-6001
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28421207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G284210Medicaid
CA00G284210Medicare PIN
CAA43726Medicare UPIN
CA00G284212Medicare PIN
CA00G284211Medicare PIN