Provider Demographics
NPI:1760412241
Name:JACKSON, DOUGLAS GILBERT I (NP)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:GILBERT
Last Name:JACKSON
Suffix:I
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:DOUGLAS
Other - Middle Name:GILBERT
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:14827 FOOTHILL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14827 FOOTHILL RD
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-9733
Practice Address - Country:US
Practice Address - Phone:805-525-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily