MEDICARE: JAMIE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1376654665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE JACKSON

Provider Business Mailing Address
First Line	:	310 HARRIS AVE
Second Line	:	SUITE A
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3249
Country	:	US
Telephone Number	:	916-418-0174
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 HARRIS AVE
Second Line	:	SUITE A
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3249
Country	:	US
Telephone Number	:	916-418-0174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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