Provider Demographics
NPI:1184734196
Name:GAIL N JACKSON MD PC
Entity type:Organization
Organization Name:GAIL N JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:N
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:310-659-2666
Mailing Address - Street 1:PO BOX 11692
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-7692
Mailing Address - Country:US
Mailing Address - Phone:310-451-2300
Mailing Address - Fax:310-451-2325
Practice Address - Street 1:1333 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1023
Practice Address - Country:US
Practice Address - Phone:310-451-2300
Practice Address - Fax:310-451-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41783207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAET547AOtherMEDICARE
CAET547AOtherMEDICARE