Provider Demographics
NPI:1659036408
Name:OTERO, JACKSON J
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:J
Last Name:OTERO
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 1:1063 MCGAW AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5505
Mailing Address - Country:US
Mailing Address - Phone:657-549-8081
Mailing Address - Fax:714-388-3727
Practice Address - Street 1:50 N HILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1949
Practice Address - Country:US
Practice Address - Phone:626-793-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst