Provider Demographics
NPI:1487689840
Name:JACKSON, JOHN CALVIN IV (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CALVIN
Last Name:JACKSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10565 BRUNSWICK RD
Mailing Address - Street 2:STE 1
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9053
Mailing Address - Country:US
Mailing Address - Phone:530-272-0501
Mailing Address - Fax:530-272-0571
Practice Address - Street 1:10565 BRUNSWICK RD
Practice Address - Street 2:STE 1
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9053
Practice Address - Country:US
Practice Address - Phone:530-272-0501
Practice Address - Fax:530-272-0571
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG37527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47126Medicare UPIN