Provider Demographics
NPI:1790173839
Name:JACKSON, TAYDAMA (RRW)
Entity Type:Individual
Prefix:
First Name:TAYDAMA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 AUBURN BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-4139
Mailing Address - Country:US
Mailing Address - Phone:916-395-3552
Mailing Address - Fax:916-473-5766
Practice Address - Street 1:4441 AUBURN BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4139
Practice Address - Country:US
Practice Address - Phone:916-395-3552
Practice Address - Fax:916-473-5766
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)