Provider Demographics
NPI:1649058561
Name:JACKSON, NATHAN IREX
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:IREX
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:NATHAN
Other - Middle Name:IREX
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:27681 CALAROGA AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4607
Mailing Address - Country:US
Mailing Address - Phone:510-571-0666
Mailing Address - Fax:
Practice Address - Street 1:2575 DEPOT RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2341
Practice Address - Country:US
Practice Address - Phone:510-571-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)