Provider Demographics
NPI:1932695970
Name:JACKSON, ANDRE PRICE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:PRICE
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:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-0591
Mailing Address - Country:US
Mailing Address - Phone:310-913-5265
Mailing Address - Fax:
Practice Address - Street 1:3450 3RD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-1443
Practice Address - Country:US
Practice Address - Phone:415-437-3990
Practice Address - Fax:415-437-3994
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 390200000X, 106H00000X
CA117677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program