Provider Demographics
NPI:1366631590
Name:JACKSON, CARNELL II
Entity Type:Individual
Prefix:
First Name:CARNELL
Middle Name:
Last Name:JACKSON
Suffix:II
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 1:2918 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4757
Mailing Address - Country:US
Mailing Address - Phone:323-497-8150
Mailing Address - Fax:323-292-5543
Practice Address - Street 1:2918 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-4757
Practice Address - Country:US
Practice Address - Phone:323-497-8150
Practice Address - Fax:323-292-5543
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)