Healthcare Provider Details

I. General information

NPI: 1174452387
Provider Name (Legal Business Name): ANDRE WAYNE JACKSON OTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 HILLTOP MALL RD STE B
RICHMOND CA
94806-2197
US

IV. Provider business mailing address

2930 HILLTOP MALL RD STE B
RICHMOND CA
94806-2197
US

V. Phone/Fax

Practice location:
  • Phone: 510-222-1075
  • Fax: 866-665-8815
Mailing address:
  • Phone: 510-222-1075
  • Fax: 866-665-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number101135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: