Provider Demographics
NPI:1245307073
Name:JACKSON, ANTHONY
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
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 1:2237 RIVER PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3836
Mailing Address - Country:US
Mailing Address - Phone:916-391-4293
Mailing Address - Fax:916-391-4247
Practice Address - Street 1:2237 RIVER PLAZA DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-3836
Practice Address - Country:US
Practice Address - Phone:916-391-4293
Practice Address - Fax:916-391-4247
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5076101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5076OtherCAARR