Individual
DR. BRENT CLARENCE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2 W FERN AVE, REDLANDS, CA 92373-5916
(909) 793-3311
Mailing address
PO BOX 10069, SAN BERNARDINO, CA 92423-0069
(909) 335-4188
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
A64902
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A649020
BLUE SHIELD OF CA
CA
05
—
00A649020
—
CA
01
—
113712291
BLUE CROSS OF CA
—
01
—
113712291 92123 0000
WPS TRICARE
—
Enumeration date
01/10/2006
Last updated
06/17/2014
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