Provider Demographics
NPI:1851594006
Name:CHARLES W JACKSON MD INC
Entity Type:Organization
Organization Name:CHARLES W JACKSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-847-6545
Mailing Address - Street 1:PO BOX 7630
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7630
Mailing Address - Country:US
Mailing Address - Phone:949-643-3345
Mailing Address - Fax:949-643-3560
Practice Address - Street 1:17122 BEACH BLVD
Practice Address - Street 2:STE. 102
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5992
Practice Address - Country:US
Practice Address - Phone:714-847-6545
Practice Address - Fax:714-847-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35311208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADF303AMedicare PIN
CAA46305Medicare UPIN