MEDICARE: MR. MARK HENRY JACKSON LCSW

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	1041C0700X	Clinical Social Worker	60523	CA

General Provider Information

NPI Number	:	1487976387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK HENRY JACKSON LCSW

Provider Business Mailing Address
First Line	:	3097 WILLOW AVE STE 9
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-4715
Country	:	US
Telephone Number	:	559-258-0545
Fax Number	:	559-820-0211

Provider Business Practice Location Address
First Line	:	3097 WILLOW AVE STE 9
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-4715
Country	:	US
Telephone Number	:	559-258-0545
Fax Number	:	559-820-0211

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

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	06/28/2024

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