Provider Demographics
NPI:1972289692
Name:JACKSON, JAIME LEIGH (RADT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:LEIGH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:LEIGH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1164 N A ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-4369
Mailing Address - Country:US
Mailing Address - Phone:805-861-3311
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1511120623101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)