Healthcare Provider Details

I. General information

NPI: 1669722708
Provider Name (Legal Business Name): ANTHONY I JACKSON MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 E ORANGEWOOD AVE STE 300
ANAHEIM CA
92806-6138
US

IV. Provider business mailing address

2390 E ORANGEWOOD AVE STE 300
ANAHEIM CA
92806-6138
US

V. Phone/Fax

Practice location:
  • Phone: 714-543-4333
  • Fax: 714-543-4398
Mailing address:
  • Phone: 714-543-4398
  • Fax: 714-543-4398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: