Provider Demographics
NPI:1548926165
Name:STEWART, JACKSON EDWARD
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:EDWARD
Last Name:STEWART
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 1:3636 N 1ST ST STE 112
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6818
Mailing Address - Country:US
Mailing Address - Phone:855-343-1057
Mailing Address - Fax:
Practice Address - Street 1:3636 N 1ST ST STE 112
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6818
Practice Address - Country:US
Practice Address - Phone:855-343-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2024-04-29
Deactivation Date:2022-11-04
Deactivation Code:
Reactivation Date:2022-11-29
Provider Licenses
StateLicense IDTaxonomies
CA135205106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty