Healthcare Provider Details

I. General information

NPI: 1063369528
Provider Name (Legal Business Name): JACKSON HOUSE EL CENTRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2364 S 2ND ST
EL CENTRO CA
92243-9642
US

IV. Provider business mailing address

2364 S 2ND ST
EL CENTRO CA
92243-9642
US

V. Phone/Fax

Practice location:
  • Phone: 760-332-3303
  • Fax: 760-332-1463
Mailing address:
  • Phone: 760-332-3303
  • Fax: 760-332-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CAROLINA RIVAS
Title or Position: COUNSELOR
Credential: AMFT
Phone: 760-332-3303