Healthcare Provider Details

I. General information

NPI: 1245375617
Provider Name (Legal Business Name): MS. VERONICA L JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/29/2026
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6526 WALNUT AVE
LONG BEACH CA
90805-2533
US

IV. Provider business mailing address

2101 MAGNOLIA AVE
LONG BEACH CA
90806-4521
US

V. Phone/Fax

Practice location:
  • Phone: 562-965-6434
  • Fax:
Mailing address:
  • Phone: 562-965-6434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1463570322
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: