Provider Demographics
NPI:1457994634
Name:JACKSON, BRANDON (RECOVERY PRACTIONER)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RECOVERY PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1873 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2604
Mailing Address - Country:US
Mailing Address - Phone:562-794-7892
Mailing Address - Fax:310-349-3660
Practice Address - Street 1:1873 W 54TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-2604
Practice Address - Country:US
Practice Address - Phone:562-794-7892
Practice Address - Fax:310-349-3660
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699246272Medicaid