Provider Demographics
NPI:1659499473
Name:JACKSON, LAMARR
Entity Type:Individual
Prefix:MR
First Name:LAMARR
Middle Name:
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 1:1424 W HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-1310
Mailing Address - Country:US
Mailing Address - Phone:559-221-1680
Mailing Address - Fax:559-221-4336
Practice Address - Street 1:1424 W HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-1310
Practice Address - Country:US
Practice Address - Phone:559-221-1680
Practice Address - Fax:559-221-4336
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health