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General NPI Number Information
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NPI Number | 1710467659
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Entity Type | Individual
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Provider Name | HARRY LEE JACKSON
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Gender | Male
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Dates
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Enumeration Date | 08/20/2018
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Last Update Date | 08/20/2018
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Provider Practice Location Address
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Address Line | 17845 IRONWOOD LANE
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City | VICTORVILLE
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State | CA
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Zip | 92395-9239
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Country | US
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Telephone | 760-373-6251
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Fax |
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Provider Business Mailing Address
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Address Line | 17845 IRONWOOD LANE SVL BOX 8205
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City | VICTORVILLE
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State | CA
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Zip | 92395
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Country | US
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Telephone | 562-230-0737
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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