Provider Demographics
NPI:1134987647
Name:MCCLAIN, JACKSON MILES
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:MILES
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 COWPER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1813
Mailing Address - Country:US
Mailing Address - Phone:510-833-4127
Mailing Address - Fax:
Practice Address - Street 1:5500 CAMPANILE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:510-833-4127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program