MEDICARE: MR. JOSEPH JACKSON III

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1700138401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH JACKSON III

Provider Business Mailing Address
First Line	:	251 E AVENUE K6
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4513
Country	:	US
Telephone Number	:	661-405-3620
Fax Number	:	661-449-3704

Provider Business Practice Location Address
First Line	:	251 E AVENUE K6 STE B
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4513
Country	:	US
Telephone Number	:	661-405-3620
Fax Number	:	661-449-3704

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

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	03/05/2026

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