Provider Demographics
NPI:1104084698
Name:JACKSON, OLLIE JOSEPH III (MD)
Entity type:Individual
Prefix:DR
First Name:OLLIE
Middle Name:JOSEPH
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9001 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #106
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1838
Mailing Address - Country:US
Mailing Address - Phone:310-273-8885
Mailing Address - Fax:310-273-8662
Practice Address - Street 1:9001 WILSHIRE BLVD
Practice Address - Street 2:SUITE #106
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1838
Practice Address - Country:US
Practice Address - Phone:310-273-8885
Practice Address - Fax:310-273-8662
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1035432086S0122X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty