MEDICARE: JACKSON J SPENCER M.S.

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	106H00000X	Marriage & Family Therapist	81152	CA
2	101YM0800X	Mental Health Counselor	110577	CA
3	106H00000X	Marriage & Family Therapist	110577	CA

General Provider Information

NPI Number	:	1831590884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON J SPENCER M.S.

Provider Business Mailing Address
First Line	:	5740 N PALM AVE STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-1800
Country	:	US
Telephone Number	:	559-547-0907
Fax Number	:	559-705-1921

Provider Business Practice Location Address
First Line	:	5740 N PALM AVE STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-1800
Country	:	US
Telephone Number	:	559-547-0907
Fax Number	:	559-705-1921

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

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	02/10/2026

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