Provider Demographics
NPI:1457742306
Name:ROBERT M JACKSON, M.D.
Entity Type:Organization
Organization Name:ROBERT M JACKSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-224-1300
Mailing Address - Street 1:41250 12TH ST W STE C
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1444
Mailing Address - Country:US
Mailing Address - Phone:661-224-1300
Mailing Address - Fax:661-224-1333
Practice Address - Street 1:41250 12TH ST W STE C
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1444
Practice Address - Country:US
Practice Address - Phone:661-224-1300
Practice Address - Fax:661-224-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50418207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14331OtherMEDICARE ID