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General NPI Number Information
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NPI Number | 1902278690
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Entity Type | Individual
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Provider Name | SCOTT A JACKSON CADC II
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Gender | Male
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Dates
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Enumeration Date | 10/21/2015
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 3148 MIDWAY DR # 113
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City | SAN DIEGO
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State | CA
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Zip | 92110-4539
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Country | US
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Telephone | 619-619-3630
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Fax | 619-362-9905
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Provider Business Mailing Address
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Address Line | 3148 MIDWAY DR # 113
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City | SAN DIEGO
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State | CA
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Zip | 92110-4539
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Country | US
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Telephone | 619-619-3630
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Fax | 619-362-9905
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | CI4400615
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | A040000816
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License Number State | CA
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