Provider Demographics
NPI:1649307562
Name:JACKSON, TORI CONSUELO (RAS)
Entity type:Individual
Prefix:
First Name:TORI
Middle Name:CONSUELO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 N STATE ST STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-1473
Mailing Address - Country:US
Mailing Address - Phone:951-652-3560
Mailing Address - Fax:951-929-2780
Practice Address - Street 1:960 N STATE ST STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1473
Practice Address - Country:US
Practice Address - Phone:951-652-3560
Practice Address - Fax:951-929-2780
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1726Medicaid