Provider Demographics
NPI:1538977780
Name:POWERS, JACKSON ROBERT
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:ROBERT
Last Name:POWERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 GOLDENROD DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-0900
Mailing Address - Country:US
Mailing Address - Phone:914-486-6771
Mailing Address - Fax:
Practice Address - Street 1:3186 AIRWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4650
Practice Address - Country:US
Practice Address - Phone:914-486-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst