Provider Demographics
NPI:1750316063
Name:JACKSON, REBECCA L (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
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 1:1175 TRANCAS ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2907
Mailing Address - Country:US
Mailing Address - Phone:707-258-6053
Mailing Address - Fax:707-253-7255
Practice Address - Street 1:1175 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2907
Practice Address - Country:US
Practice Address - Phone:707-258-6053
Practice Address - Fax:707-253-7255
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60623208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE50207Medicare UPIN
CA00G606230Medicare ID - Type Unspecified