Provider Demographics
NPI:1487821559
Name:TAYLOR, JACKSON B (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:JACKSON
Other - Last Name:TAYLOR
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4398 STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-7922
Mailing Address - Country:US
Mailing Address - Phone:757-469-5474
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-719-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99013392086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery