Provider Demographics
NPI:1609883438
Name:JACKSON, BRUCE K (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:K
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 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-547-9922
Mailing Address - Fax:310-547-4673
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:STE. 300
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-372-1156
Practice Address - Fax:310-372-6504
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24716207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA24716GMedicare ID - Type Unspecified
CAWA24716JMedicare ID - Type Unspecified
CAWA24716KMedicare ID - Type Unspecified
WA24716HMedicare ID - Type Unspecified
WA24716ICMedicare ID - Type Unspecified
CAA24090Medicare UPIN