Basic Information
| Provider Information | |||||||||
| NPI: | 1912231721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ROLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5571 W HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592763559 | ||||||||
| FaxNumber: | 5592763559 | ||||||||
| Practice Location | |||||||||
| Address1: | 2772 S. MLK BLVD. | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937065345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592654800 | ||||||||
| FaxNumber: | 5592654823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2009 | ||||||||
| LastUpdateDate: | 09/25/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.