Provider Demographics
NPI:1962446575
Name:JACKSON, JERILYN DE VON (MD)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:DE VON
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 1:1772 PINER RD
Mailing Address - Street 2:PMB 16
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7401
Mailing Address - Country:US
Mailing Address - Phone:707-318-9670
Mailing Address - Fax:707-571-8446
Practice Address - Street 1:1110 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4606
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67649207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G676492Medicaid
CA00G676492Medicaid
CA00G676491Medicare ID - Type Unspecified