Provider Demographics
NPI:1942351671
Name:JACKSON, BRYAN EDWARD (BRIENING)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:EDWARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BRIENING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 LYNBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5303
Mailing Address - Country:US
Mailing Address - Phone:925-565-9348
Mailing Address - Fax:415-206-6875
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-4288
Practice Address - Fax:415-206-6875
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)