Jerilyn De Von Jackson, M.D.

Primary specialty

Emergency Medicine PhysicianTaxonomy code 207P00000X

License

G67649 Issued in CA

Practice address

1110 N Dutton Ave
Santa Rosa, CA 95401-4606

Phone

(707) 303-3600

NPI assigned

Jun 15, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Santa Rosa Community Healt Centers

  • Federally Qualified Health Center (FQHC)
  • Santa Rosa, CA
  • NPI 1023439759
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150329600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1532476800000",
    "number": "1962446575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1772 PINER RD",
            "address_2": "PMB 16",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954037401",
            "telephone_number": "707-318-9670",
            "fax_number": "707-571-8446"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1110 N DUTTON AVE",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954014606",
            "telephone_number": "707-303-3600"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3569 Round Barn Cir",
            "address_2": "Vista Family Health Center, Office Green",
            "address_purpose": "LOCATION",
            "city": "Santa Rosa",
            "state": "CA",
            "postal_code": "954031757",
            "country_code": "US",
            "telephone_number": "707-303-3600 x494",
            "fax_number": "707-303-3609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "JERILYN",
        "middle_name": "DE VON",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-15",
        "last_updated": "2018-07-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "CA",
            "license": "G67649",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00G676492",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Colleen C Jackson
• Erin Dickenson Jackson, LMFT
• Gabrielle Jackson
• Jasmine Jackson, D.C.
• Jenna Jackson
• Jon Gustaf Jackson, M.D.
• Michelle Lorraine Jackson, ASW
• Joshua Jacober, MD
• Gerald D. Jacobs
• Robert Louis Jacobs

• Emergency Medicine Physician in Santa Rosa, CA
• Providers in Santa Rosa, CA by specialty
• Emergency Medicine Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.