MEDICARE: CHARLESTON R 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		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7112	OTHER	CA	PROVIDER NUMBER

General Provider Information

NPI Number	:	1528288107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLESTON R JACKSON

Provider Business Mailing Address
First Line	:	8031 SEPULVEDA BLVD APT 33
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91402-4432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5655 LINDERO CANYON RD STE 302
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-4045
Country	:	US
Telephone Number	:	818-997-6876
Fax Number	:

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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