Healthcare Provider Details

I. General information

NPI: 1487976387
Provider Name (Legal Business Name): MARK HENRY JACKSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3097 WILLOW AVE STE 9
CLOVIS CA
93612-4715
US

IV. Provider business mailing address

3097 WILLOW AVE STE 9
CLOVIS CA
93612-4715
US

V. Phone/Fax

Practice location:
  • Phone: 559-258-0545
  • Fax: 559-820-0211
Mailing address:
  • Phone: 559-258-0545
  • Fax: 559-820-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number60523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: