Provider Demographics
NPI:1811966468
Name:JACKSON, WILLIAM W (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-6218
Mailing Address - Country:US
Mailing Address - Phone:714-935-0073
Mailing Address - Fax:714-935-0075
Practice Address - Street 1:40740 CALIFORNIA OAKS RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5727
Practice Address - Country:US
Practice Address - Phone:951-304-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78919207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G789192Medicaid
CA00G789190Medicare PIN
CA00G789192Medicaid