Healthcare Provider Details

I. General information

NPI: 1093446387
Provider Name (Legal Business Name): TYRON JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2022
Last Update Date: 06/18/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

IV. Provider business mailing address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax:
Mailing address:
  • Phone: 951-682-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: