Provider Demographics
NPI:1831911742
Name:WATERS JACKSON, JERRELLE CLEON
Entity type:Individual
Prefix:
First Name:JERRELLE
Middle Name:CLEON
Last Name:WATERS JACKSON
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 1:23 HARBOR RD # 23
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94124-2819
Mailing Address - Country:US
Mailing Address - Phone:650-770-3917
Mailing Address - Fax:
Practice Address - Street 1:23 HARBOR RD # 23
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-2819
Practice Address - Country:US
Practice Address - Phone:650-770-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician