Individual
JACKSON W PENRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
27700 MEDICAL CENTER ROAD-RADIOLOGY DEPARTMENT, MISSION VIEJO, CA 92691-6426
(949) 364-7744
Mailing address
DEPT LA 21789, PASADENA, CA 91185-1789
(949) 263-8620
(800) 409-7005
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
A114302
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A1143020
BS/BC OF CA
CA
05
—
0A1143020
—
CA
05
—
1003055401
—
CA
Enumeration date
02/10/2009
Last updated
07/29/2014
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