Provider Demographics
NPI:1295585933
Name:MALLERY, JACKSON SCOTT
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:SCOTT
Last Name:MALLERY
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 1:8410 CANDYCANE LN
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5952
Mailing Address - Country:US
Mailing Address - Phone:916-633-9116
Mailing Address - Fax:
Practice Address - Street 1:3101 SUNSET BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3097
Practice Address - Country:US
Practice Address - Phone:916-773-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician