Provider Demographics
NPI:1265143507
Name:JACKSON, LADALE SR
Entity type:Individual
Prefix:MR
First Name:LADALE
Middle Name:
Last Name:JACKSON
Suffix:SR
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 1:5601 W SLAUSON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6576
Mailing Address - Country:US
Mailing Address - Phone:310-910-0406
Mailing Address - Fax:310-928-0981
Practice Address - Street 1:5601 W SLAUSON AVE STE 130
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6576
Practice Address - Country:US
Practice Address - Phone:310-910-0406
Practice Address - Fax:310-928-0981
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath