Provider Demographics
NPI:1689981599
Name:JACKSON, JEREMY BRANDON (MS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRANDON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18142
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-8142
Mailing Address - Country:US
Mailing Address - Phone:310-704-1971
Mailing Address - Fax:
Practice Address - Street 1:165 W HOSPITALITY LN STE 11
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3322
Practice Address - Country:US
Practice Address - Phone:866-664-0426
Practice Address - Fax:909-619-3914
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker