Provider Demographics
NPI:1255407318
Name:JACKSON, FREDERIC LESLIE (DO, MPH)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:LESLIE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 OLD RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-6727
Mailing Address - Country:US
Mailing Address - Phone:760-855-5423
Mailing Address - Fax:877-359-0651
Practice Address - Street 1:2402 OLD RANCH RD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-6727
Practice Address - Country:US
Practice Address - Phone:760-855-5423
Practice Address - Fax:877-359-0651
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102032316207Q00000X
FLOS0004196207Q00000X
CA20A10056207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G17176Medicare UPIN