Provider Demographics
NPI:1821729880
Name:JACKSON, CRYSTAL AMBER
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMBER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CARMEN LN
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7729
Mailing Address - Country:US
Mailing Address - Phone:805-332-4568
Mailing Address - Fax:
Practice Address - Street 1:412 E TUNNELL ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4146
Practice Address - Country:US
Practice Address - Phone:805-925-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1452921221101YA0400X
CA15788-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033665526Medicaid