Provider Demographics
NPI:1306146345
Name:JACKSON, LOUIS II
Entity type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:
Last Name:JACKSON
Suffix:II
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 1:2029 W SHIELDS AVE
Mailing Address - Street 2:APT 202
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-3261
Mailing Address - Country:US
Mailing Address - Phone:559-394-8275
Mailing Address - Fax:
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-253-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker