Provider Demographics
NPI:1649507484
Name:ANTIOCH SUBSTANCE ABUSE PROGRAMS
Entity type:Organization
Organization Name:ANTIOCH SUBSTANCE ABUSE PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:ESTER
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-307-3482
Mailing Address - Street 1:3838 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-2703
Mailing Address - Country:US
Mailing Address - Phone:559-307-3482
Mailing Address - Fax:559-294-0303
Practice Address - Street 1:3838 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-2703
Practice Address - Country:US
Practice Address - Phone:559-307-3482
Practice Address - Fax:559-294-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder