Provider Demographics
NPI:1588855605
Name:JACKSON, ANDREA V (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 SUTTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3006
Mailing Address - Country:US
Mailing Address - Phone:415-885-7788
Mailing Address - Fax:
Practice Address - Street 1:2356 SUTTER ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3006
Practice Address - Country:US
Practice Address - Phone:415-885-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-232619207V00000X
CAA116955207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology