Provider Demographics
NPI:1306100722
Name:CROUGH, JACKSON THOMAS (DPM)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:THOMAS
Last Name:CROUGH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 E TAHQUITZ CANYON WAY
Mailing Address - Street 2:SUITE 200-096
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6784
Mailing Address - Country:US
Mailing Address - Phone:760-507-2070
Mailing Address - Fax:760-507-2071
Practice Address - Street 1:47647 CALEO BAY DR STE 110
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8857
Practice Address - Country:US
Practice Address - Phone:760-507-2070
Practice Address - Fax:760-507-2071
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5290213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery