MEDICARE: TANDREYA JACKSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	101Y00000X	Counselor
2	171M00000X	Case Manager/Care Coordinator
3	101YM0800X	Mental Health Counselor	CA
4	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1730637125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANDREYA JACKSON

Provider Business Mailing Address
First Line	:	160 GLEN COVE MARINA RD E STE 102
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94591-7290
Country	:	US
Telephone Number	:	707-648-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 GLEN COVE MARINA RD E STE 102
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94591-7290
Country	:	US
Telephone Number	:	707-648-2000
Fax Number	:

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

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	04/03/2026

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