Provider Demographics
NPI:1275313223
Name:JACKSON, JAMES FRED
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:FRED
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:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:ROUND MOUNTAIN
Mailing Address - State:CA
Mailing Address - Zip Code:96084-0107
Mailing Address - Country:US
Mailing Address - Phone:530-782-6574
Mailing Address - Fax:
Practice Address - Street 1:3590 EL PORTAL DR APT 15
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-3154
Practice Address - Country:US
Practice Address - Phone:530-722-1114
Practice Address - Fax:530-722-1115
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)