Provider Demographics
NPI:1821562315
Name:JACKSON, RONNIE JEROME
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:JEROME
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:BHS HOME OFFICE
Mailing Address - Street 2:15519 CRENSHAW BLVD.
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249
Mailing Address - Country:US
Mailing Address - Phone:310-679-9126
Mailing Address - Fax:
Practice Address - Street 1:BHS HOLLYWOOD RECOVERY CENTER
Practice Address - Street 2:6838 SUNSET BLVD
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028
Practice Address - Country:US
Practice Address - Phone:323-461-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator