Provider Demographics
NPI:1528247061
Name:JACKSON, MARYAM VIII
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:JACKSON
Suffix:VIII
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 S TWIN OAKS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-7309
Mailing Address - Country:US
Mailing Address - Phone:800-417-4444
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:2701 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3443
Practice Address - Country:US
Practice Address - Phone:714-973-2022
Practice Address - Fax:714-835-6954
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD56397Medicaid