Healthcare Provider Details

I. General information

NPI: 1821484643
Provider Name (Legal Business Name): JACK MCNERTNEY JR. RAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1164
HOOPA CA
95546-1164
US

IV. Provider business mailing address

PO BOX 1164
HOOPA CA
95546-1164
US

V. Phone/Fax

Practice location:
  • Phone: 760-453-8255
  • Fax:
Mailing address:
  • Phone: 760-744-2104
  • Fax: 760-744-1382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberM1307231136
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: