| Doctor Name: | MR. HOLLI VERN JACKSON |
| NPI Number: | 1699100511 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | L.C.S.W. |
| License Number: | 27403 |
| Business Practice Address: | 64236 Second Ave. Happy Camp, CA - 96039 |
| Business Phone Number: | 5304931600 |
| Business Fax Number: | |
| Mailing Address: | Po Box 1020, CRESCENT CITY |
| State: | CA |
| Postal Code: | 955311020 |
| Phone Number: | 7072184686 |
| Fax Number: | |
| NPI Enumeration Date: | 09/10/2013 |
| NPI Last Update Date: | 09/03/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 27403 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |