Provider Demographics
NPI:1487823324
Name:KEITH A JACKSON MD LIMITED
Entity Type:Organization
Organization Name:KEITH A JACKSON MD LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-279-4221
Mailing Address - Street 1:8010 FROST ST
Mailing Address - Street 2:503
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2778
Mailing Address - Country:US
Mailing Address - Phone:858-279-4221
Mailing Address - Fax:858-279-4223
Practice Address - Street 1:8010 FROST ST
Practice Address - Street 2:503
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2778
Practice Address - Country:US
Practice Address - Phone:858-279-4221
Practice Address - Fax:858-279-4223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58187174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty