Healthcare Provider Details

I. General information

NPI: 1386160661
Provider Name (Legal Business Name): ROBERT JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 GEARY BLVD # 590932
SAN FRANCISCO CA
94118-3318
US

IV. Provider business mailing address

3245 GEARY BLVD # 590932
SAN FRANCISCO CA
94118-3318
US

V. Phone/Fax

Practice location:
  • Phone: 415-424-4514
  • Fax: 628-465-1310
Mailing address:
  • Phone: 415-424-4514
  • Fax: 415-871-2574

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: