Provider Demographics
NPI:1518079565
Name:JACKSON, BLAINE KENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:KENTON
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 1:773 ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2031
Mailing Address - Country:US
Mailing Address - Phone:858-259-9708
Mailing Address - Fax:858-259-9689
Practice Address - Street 1:773 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075
Practice Address - Country:US
Practice Address - Phone:858-259-9708
Practice Address - Fax:858-259-9689
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672881Medicare ID - Type Unspecified
CAH41868Medicare UPIN
CAA67288Medicare ID - Type Unspecified