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General NPI Number Information
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NPI Number | 1154288256
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Entity Type | Individual
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Provider Name | LYNETTE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 01/08/2026
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Last Update Date | 01/08/2026
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Provider Practice Location Address
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Address Line | 2200 STANDIFORD AVE APT 126
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City | MODESTO
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State | CA
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Zip | 95350-6540
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Country | US
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Telephone | 209-569-3351
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Fax | 209-290-3587
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Provider Business Mailing Address
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Address Line | 2200 STANDIFORD AVE APT 126
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City | MODESTO
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State | CA
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Zip | 95350-6540
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Country | US
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Telephone | 209-569-3351
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Fax | 209-290-3587
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 202030210947
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number | 202030210947
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 202030210947
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | 202030210947
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number | 202030210947
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 202030210947
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License Number State | CA
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Taxonomy #7
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Taxonomy Code | 175L00000X
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Taxonomy Name | Homeopath
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License Number | 202030210947
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License Number State | CA
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Taxonomy #8
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Taxonomy Code | 251300000X
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Taxonomy Name | Local Education Agency (LEA)
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License Number | 202030210947
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License Number State | CA
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Taxonomy #9
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 202030210947
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License Number State | CA
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Taxonomy #10
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 202030210947
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License Number State | CA
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Taxonomy #11
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 202030210947
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License Number State | CA
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