Provider Demographics
NPI:1700982444
Name:JACKSON-NOVAK, TERESA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:JACKSON-NOVAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39407 VISTA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3283
Mailing Address - Country:US
Mailing Address - Phone:760-423-6706
Mailing Address - Fax:
Practice Address - Street 1:39407 VISTA DEL SOL
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3283
Practice Address - Country:US
Practice Address - Phone:760-423-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA715892083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0789290OtherBLUE CROSS BLUE SHIELD
WA2099880Medicaid
AZ851685Medicaid
AZ2Z1286OtherHEALTHNET
AZAZ0789290OtherBLUE CROSS BLUE SHIELD