Provider Demographics
NPI:1710467659
Name:JACKSON, HARRY LEE
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:LEE
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 1:17845 IRONWOOD LANE
Mailing Address - Street 2:SVL BOX 8205
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:562-230-0737
Mailing Address - Fax:
Practice Address - Street 1:17845 IRONWOOD LANE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-9239
Practice Address - Country:US
Practice Address - Phone:760-373-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty