Healthcare Provider Details

I. General information

NPI: 1649507484
Provider Name (Legal Business Name): ANTIOCH SUBSTANCE ABUSE PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 11/16/2009
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

3838 N WEST AVE
FRESNO CA
93705-2703
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 TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PROF. JEROME ESTER JACKSON
Title or Position: PRESIDENT
Credential:
Phone: 559-307-3482