Individual
MR. BRANDON JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RECOVERY PRACTIONER
Contact information
Practice address
1873 W 54TH ST, LOS ANGELES, CA 90062-2604
(562) 794-7892
(310) 349-3660
Mailing address
1873 W 54TH ST, LOS ANGELES, CA 90062-2604
(562) 794-7892
(310) 349-3660
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
—
—
225400000X
Rehabilitation Practitioner
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1699246272
—
CA
Enumeration date
10/21/2019
Last updated
10/21/2019
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