MEDICARE: CHARMAINE JACKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW78456	CA

General Provider Information

NPI Number	:	1407181712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARMAINE JACKSON LCSW

Provider Business Mailing Address
First Line	:	2640 LAKE AVE APT B
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-1943
Country	:	US
Telephone Number	:	909-291-5766
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 E COLORADO BLVD STE 180&2ND
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-6143
Country	:	US
Telephone Number	:	626-941-7645
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	12/13/2024

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