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NPI Code Detail

MEDICARE: MR. LEE JACKSON

MEDICARE: MR. LEE 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
1172V00000XCommunity Health Worker

General Provider Information

NPI Number : 1720777634
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LEE JACKSON
Provider Business Mailing Address
First Line : 1076 HOWARD ST
Second Line : SECOND FL
City : SAN FRANCISCO
State : CA
Zip : 94103-2820
Country : US
Telephone Number : 628-217-7854
Fax Number : 415-217-7868
Provider Business Practice Location Address
First Line : 1076 HOWARD ST
Second Line : SECOND FL
City : SAN FRANCISCO
State : CA
Zip : 94103-2820
Country : US
Telephone Number : 628-217-7854
Fax Number : 415-217-7868
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/05/2023
Last Update Date : 01/18/2026

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