Healthcare Provider Details

I. General information

NPI: 1154625671
Provider Name (Legal Business Name): MR. WILLIAM CALVIN JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2010
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3845 SPRING DR
SPRING VALLEY CA
91977-1030
US

IV. Provider business mailing address

3845 SPRING DR
SPRING VALLEY CA
91977-1030
US

V. Phone/Fax

Practice location:
  • Phone: 619-797-1090
  • Fax: 619-797-1091
Mailing address:
  • Phone: 619-797-1090
  • Fax: 619-797-1091

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: