Provider Demographics
NPI:1720317175
Name:JACKSON, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:JACKSON
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 1:650 CHARLES E YOUNG DR S
Mailing Address - Street 2:EHS SPH UCLA BOX 56-070
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1772
Mailing Address - Country:US
Mailing Address - Phone:310-206-8522
Mailing Address - Fax:310-794-2106
Practice Address - Street 1:650 CHARLES E YOUNG DR S
Practice Address - Street 2:EHS SPH UCLA BOX 56-070
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1772
Practice Address - Country:US
Practice Address - Phone:310-206-8522
Practice Address - Fax:310-794-2106
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG34076208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics