MEDICARE: MR. ALEXANDER ENACIO JACKSON LCSW

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	1041C0700X	Clinical Social Worker	LCS19196	CA

General Provider Information

NPI Number	:	1801816244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEXANDER ENACIO JACKSON LCSW

Provider Business Mailing Address
First Line	:	3701 PARK BOULEVARD WAY
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94610-2837
Country	:	US
Telephone Number	:	510-530-0767
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 BANCROFT AVE
Second Line	:	SUITE 125-D, ALAMEDA COUNTY BHCS
City	:	OAKLAND
State	:	CA
Zip	:	94605-2403
Country	:	US
Telephone Number	:	510-777-3877
Fax Number	:	510-777-3880

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	04/28/2009

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