Provider Demographics
NPI:1386181402
Name:JACKSON, TRAMAINE ALAN
Entity Type:Individual
Prefix:
First Name:TRAMAINE
Middle Name:ALAN
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 1:2523 EL PORTAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3305
Mailing Address - Country:US
Mailing Address - Phone:510-418-7349
Mailing Address - Fax:510-439-3129
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-418-7349
Practice Address - Fax:510-439-3129
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386181402Medicaid