MEDICARE: MS. KAREN LOUISE HOLLINGER JACKSON MFT

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	106H00000X	Marriage & Family Therapist	MFT6643	CA
2	101YM0800X	Mental Health Counselor	MFT6643	CA
3	101YP2500X	Professional Counselor	MFT6643	CA

General Provider Information

NPI Number	:	1518056043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN LOUISE HOLLINGER JACKSON MFT

Provider Business Mailing Address
First Line	:	2258 SANTA CLARA AVE
Second Line	:	STE 4
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4473
Country	:	US
Telephone Number	:	510-522-4632
Fax Number	:	510-522-2359

Provider Business Practice Location Address
First Line	:	2258 SANTA CLARA AVE
Second Line	:	STE 4
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4473
Country	:	US
Telephone Number	:	510-522-4632
Fax Number	:	510-522-2359

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/29/2007

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Directions to “ MS. KAREN LOUISE HOLLINGER JACKSON MFT” Practice Location

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