Individual
JERILYN DE VON JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1110 N DUTTON AVE, SANTA ROSA, CA 95401-4606
(707) 303-3600
Mailing address
1772 PINER RD, PMB 16, SANTA ROSA, CA 95403-7401
(707) 318-9670
(707) 571-8446
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
G67649
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G676492
—
CA
Enumeration date
06/15/2006
Last updated
07/25/2018
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