Provider Demographics
NPI:1124366133
Name:JACKSON, BRYON D (CAARR)
Entity Type:Individual
Prefix:
First Name:BRYON
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CAARR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 S. MAIN STREET
Mailing Address - Street 2:#104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003
Mailing Address - Country:US
Mailing Address - Phone:323-372-5900
Mailing Address - Fax:
Practice Address - Street 1:5930 S MAIN ST
Practice Address - Street 2:#104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1284
Practice Address - Country:US
Practice Address - Phone:323-372-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)