Healthcare Provider Details

I. General information

NPI: 1982254686
Provider Name (Legal Business Name): JASON ALLEN MACK MSWI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 MISSION AVE
CARMICHAEL CA
95608-2946
US

IV. Provider business mailing address

3637 MISSION AVE
CARMICHAEL CA
95608-2946
US

V. Phone/Fax

Practice location:
  • Phone: 916-485-4175
  • Fax:
Mailing address:
  • Phone: 916-485-4175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5593
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: