Provider Demographics
NPI:1982722419
Name:JACKSON, DARVALE LAVON
Entity Type:Individual
Prefix:MR
First Name:DARVALE
Middle Name:LAVON
Last Name:JACKSON
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 1:1429 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1724
Mailing Address - Country:US
Mailing Address - Phone:408-832-5185
Mailing Address - Fax:
Practice Address - Street 1:3695 HIGH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2105
Practice Address - Country:US
Practice Address - Phone:510-434-7990
Practice Address - Fax:510-434-7991
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Yes172V00000XOther Service ProvidersCommunity Health Worker