Provider Demographics
NPI:1407181688
Name:JACKSON, ALSTELMA TOLIVER
Entity Type:Individual
Prefix:
First Name:ALSTELMA
Middle Name:TOLIVER
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 1:2515 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-8947
Mailing Address - Country:US
Mailing Address - Phone:559-217-1157
Mailing Address - Fax:559-294-0303
Practice Address - Street 1:3838 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-2703
Practice Address - Country:US
Practice Address - Phone:559-217-1157
Practice Address - Fax:559-294-0303
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool