Provider Demographics
NPI:1356476501
Name:JACKSON, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E COOK ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5750
Mailing Address - Country:US
Mailing Address - Phone:805-922-1991
Mailing Address - Fax:
Practice Address - Street 1:604 W OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6630
Practice Address - Country:US
Practice Address - Phone:805-346-8185
Practice Address - Fax:805-346-8656
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)