Provider Demographics
NPI:1164845400
Name:JACKSON, KEVIN SR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E CARNAGIE DR # 210 SAN BERNARDINO CA 92415
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0530
Mailing Address - Country:US
Mailing Address - Phone:909-386-9767
Mailing Address - Fax:909-381-2172
Practice Address - Street 1:621 E CARNAGIE DR # 210 SAN BERNARDINO CA 92415
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-3919
Practice Address - Country:US
Practice Address - Phone:909-386-9767
Practice Address - Fax:909-381-2172
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)