Provider Demographics
NPI:1184846529
Name:JACKSON, MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
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 1:3613 VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4522
Mailing Address - Country:US
Mailing Address - Phone:760-758-5340
Mailing Address - Fax:760-758-5502
Practice Address - Street 1:3613 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4522
Practice Address - Country:US
Practice Address - Phone:760-758-5340
Practice Address - Fax:760-758-5502
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102012207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGG162ZOtherPTAN