Healthcare Provider Details

I. General information

NPI: 1154288256
Provider Name (Legal Business Name): LYNETTE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 STANDIFORD AVE APT 126
MODESTO CA
95350-6540
US

IV. Provider business mailing address

2200 STANDIFORD AVE APT 126
MODESTO CA
95350-6540
US

V. Phone/Fax

Practice location:
  • Phone: 209-569-3351
  • Fax: 209-290-3587
Mailing address:
  • Phone: 209-569-3351
  • Fax: 209-290-3587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number202030210947
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number202030210947
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number202030210947
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number202030210947
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number202030210947
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number202030210947
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number202030210947
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number202030210947
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number202030210947
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number202030210947
License Number StateCA
# 11
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number202030210947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: