Provider Demographics
NPI:1013143395
Name:JACKSON, WILLIE LEE JR
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:LEE
Last Name:JACKSON
Suffix:JR
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 1:157 SANTA BARBARA PLZ
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-2508
Mailing Address - Country:US
Mailing Address - Phone:323-293-2717
Mailing Address - Fax:
Practice Address - Street 1:157 SANTA BARBARA PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-2508
Practice Address - Country:US
Practice Address - Phone:323-293-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)