Basic Information
| Provider Information | |||||||||
| NPI: | 1134492069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | MFC52239 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 ORANGE ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519551462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC52239 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.