Provider Demographics
NPI:1922647346
Name:JACKSON, RONALD WAYNE (RADT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3519
Mailing Address - Country:US
Mailing Address - Phone:909-932-1069
Mailing Address - Fax:
Practice Address - Street 1:939 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3519
Practice Address - Country:US
Practice Address - Phone:909-889-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1367361019101YA0400X
CARADT78265405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No405300000XOther Service ProvidersPrevention Professional