Provider Demographics
NPI:1073338208
Name:JACKSON, HAROLD
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name: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 1:2121 AVENUE OF THE STARS STE 800
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-5080
Mailing Address - Country:US
Mailing Address - Phone:310-936-3512
Mailing Address - Fax:
Practice Address - Street 1:2121 AVENUE OF THE STARS STE 800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-5080
Practice Address - Country:US
Practice Address - Phone:310-936-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator