Provider Demographics
NPI:1073511127
Name:JACKSON, WESLEY GORDON (MD)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:GORDON
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 1:2441 SAMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5495
Mailing Address - Country:US
Mailing Address - Phone:559-323-9330
Mailing Address - Fax:
Practice Address - Street 1:2441 SAMPLE AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-5495
Practice Address - Country:US
Practice Address - Phone:559-323-9330
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35382208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery