Provider Demographics
NPI:1699745471
Name:LEE-JACKSON, FAITH (MD)
Entity type:Individual
Prefix:DR
First Name:FAITH
Middle Name:
Last Name:LEE-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NORTH WATERMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNANDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5105
Mailing Address - Country:US
Mailing Address - Phone:909-883-8611
Mailing Address - Fax:909-883-8611
Practice Address - Street 1:1700 NORTH WATERMAN AVENUE
Practice Address - Street 2:
Practice Address - City:SAN BERNANDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5105
Practice Address - Country:US
Practice Address - Phone:909-883-8611
Practice Address - Fax:909-881-5707
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA634520Medicaid
H03347Medicare UPIN
CA00A634520Medicare PIN