Healthcare Provider Details

I. General information

NPI: 1518292796
Provider Name (Legal Business Name): JEROME ESTER JACKSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 10/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 N WEST AVE
FRESNO CA
93705-2703
US

IV. Provider business mailing address

2515 MAGNOLIA AVE
CLOVIS CA
93611-8947
US

V. Phone/Fax

Practice location:
  • Phone: 559-307-3482
  • Fax: 559-294-0303
Mailing address:
  • Phone: 559-307-3482
  • Fax: 559-294-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: