Provider Demographics
NPI:1033462932
Name:JACKSON, GARY D
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:D
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R
Mailing Address - Street 1:1800 WEST BADILLO #919
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790
Mailing Address - Country:US
Mailing Address - Phone:626-960-3258
Mailing Address - Fax:
Practice Address - Street 1:4610 SANTA ANITA BLVD, SUITE D
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731
Practice Address - Country:US
Practice Address - Phone:626-453-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3055-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)