Provider Demographics
NPI:1720777634
Name:JACKSON, LEE
Entity type:Individual
Prefix:MR
First Name:LEE
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 1:1076 HOWARD ST
Mailing Address - Street 2:SECOND FL
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2820
Mailing Address - Country:US
Mailing Address - Phone:628-217-7854
Mailing Address - Fax:415-217-7868
Practice Address - Street 1:1076 HOWARD ST
Practice Address - Street 2:SECOND FL
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2820
Practice Address - Country:US
Practice Address - Phone:628-217-7854
Practice Address - Fax:415-217-7868
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker