Healthcare Provider Details

I. General information

NPI: 1922647346
Provider Name (Legal Business Name): RONALD WAYNE JACKSON RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 N D ST
SAN BERNARDINO CA
92410-3519
US

IV. Provider business mailing address

939 N D ST
SAN BERNARDINO CA
92410-3519
US

V. Phone/Fax

Practice location:
  • Phone: 909-889-6519
  • Fax:
Mailing address:
  • Phone: 909-932-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1367361019
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRADT78265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: