Provider Demographics
NPI:1245481266
Name:JACKSON, TIMOTHY J (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
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:PO BOX 90730
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-0730
Mailing Address - Country:US
Mailing Address - Phone:626-795-8051
Mailing Address - Fax:
Practice Address - Street 1:800 S RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3229
Practice Address - Country:US
Practice Address - Phone:626-795-8051
Practice Address - Fax:626-795-0356
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102360207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
ILPENDINGMedicaid