Provider Demographics
NPI:1225574759
Name:JACKSON, FREDERICK
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:JACKSON
Suffix:
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 1:2090 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4902
Mailing Address - Country:US
Mailing Address - Phone:925-676-2580
Mailing Address - Fax:925-798-3359
Practice Address - Street 1:2090 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4902
Practice Address - Country:US
Practice Address - Phone:925-676-2580
Practice Address - Fax:925-798-3359
Is Sole Proprietor?:No
Enumeration Date:2017-01-08
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1239870916101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1239870916OtherCCAPP