MEDICARE: ANDRE WAYNE JACKSON OTHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	101135	CA

General Provider Information

NPI Number	:	1174452387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRE WAYNE JACKSON OTHER

Provider Business Mailing Address
First Line	:	2930 HILLTOP MALL RD STE B
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-2197
Country	:	US
Telephone Number	:	510-222-1075
Fax Number	:	866-665-8815

Provider Business Practice Location Address
First Line	:	2930 HILLTOP MALL RD STE B
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-2197
Country	:	US
Telephone Number	:	510-222-1075
Fax Number	:	866-665-8815

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2026
Last Update Date	:	05/14/2026

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