Provider Demographics
NPI:1528181666
Name:JACKSON, THOMAS BURTON (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BURTON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:41750 RANCHO LAS PALMAS DR STE D2
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5512
Mailing Address - Country:US
Mailing Address - Phone:760-895-4332
Mailing Address - Fax:760-895-4324
Practice Address - Street 1:41750 RANCHO LAS PALMAS DR STE D2
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-5512
Practice Address - Country:US
Practice Address - Phone:760-895-4332
Practice Address - Fax:760-895-4324
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-0275332084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAET517YMedicare PIN