Provider Demographics
NPI:1154625671
Name:JACKSON, WILLIAM CALVIN
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:CALVIN
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 1:3845 SPRING DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1030
Mailing Address - Country:US
Mailing Address - Phone:619-797-1090
Mailing Address - Fax:619-797-1091
Practice Address - Street 1:3845 SPRING DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1030
Practice Address - Country:US
Practice Address - Phone:619-797-1090
Practice Address - Fax:619-797-1091
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health