Individual
SAM JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LAC
Contact information
Practice address
4250 E FLORIAN AVE, BUILDING #1, MESA, AZ 85206-2797
(480) 844-1653
Mailing address
924 N COUNTRY CLUB DR, BUILDING #1, MESA, AZ 85201-4108
(480) 969-3800
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
LAC-15314
AZ
Other
Enumeration date
02/16/2016
Last updated
02/16/2016
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