Healthcare Provider Details

I. General information

NPI: 1861553182
Provider Name (Legal Business Name): DANIEL F JACKSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NEVIN AVE
RICHMOND CA
94801-3143
US

IV. Provider business mailing address

901 NEVIN AVE
RICHMOND CA
94801-3143
US

V. Phone/Fax

Practice location:
  • Phone: 510-307-1639
  • Fax: 510-307-1615
Mailing address:
  • Phone: 510-307-1639
  • Fax: 510-307-1615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 17181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: