Healthcare Provider Details

I. General information

NPI: 1558178665
Provider Name (Legal Business Name): KINGDOM BUILDERS TRANSITIONAL HOUSING PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 INTERNATIONAL BLVD
OAKLAND CA
94601-1018
US

IV. Provider business mailing address

2321 INTERNATIONAL BLVD
OAKLAND CA
94601-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-326-2446
  • Fax:
Mailing address:
  • Phone: 510-326-2446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ERNEST L JACKSON
Title or Position: DIRECTOR
Credential: DMIN
Phone: 415-860-6767