Provider Information for 1104084698
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Dr. OLLIE JOSEPH JACKSON III M.D.
Other Names:Other Name:Dr. JAY JACKSON M.D.Sex: Male
NPI: 1104084698
Last Updated: 2023-03-15
Certification Date: 2023-03-15
Certification Date: 2023-03-15
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1104084698 | ||||||||||||
| Enumeration Date | 2008-05-30 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 9001 WILSHIRE BLVD SUITE #106 BEVERLY HILLS, CA 90211-1838 United States Phone: 310-273-8885 | Fax:310-273-8662 | ||||||||||||
| Primary Practice Address | 9001 WILSHIRE BLVD SUITE #106 BEVERLY HILLS, CA 90211-1838 United States Phone: 310-273-8885 | Fax:310-273-8662 | ||||||||||||
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