Provider Demographics
NPI:1265599633
Name:JACKS, BRIAN PAUL (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL
Last Name:JACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:462 N LINDEN
Mailing Address - Street 2:SUITE 441 BRIAN P JACKS MD
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212
Mailing Address - Country:US
Mailing Address - Phone:310-274-0684
Mailing Address - Fax:310-274-5049
Practice Address - Street 1:462 N LINDEN
Practice Address - Street 2:SUITE 441 BRIAN P JACKS MD
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212
Practice Address - Country:US
Practice Address - Phone:310-274-0684
Practice Address - Fax:310-274-5049
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA231892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A23189Medicare ID - Type Unspecified