Healthcare Provider Details

I. General information

NPI: 1407780638
Provider Name (Legal Business Name): KIRSTEN L JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/14/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9713 SANTA MONICA BLVD STE 201
BEVERLY HILLS CA
90210-4236
US

IV. Provider business mailing address

PO BOX 3023
GLENDALE CA
91221-0023
US

V. Phone/Fax

Practice location:
  • Phone: 323-486-3014
  • Fax:
Mailing address:
  • Phone: 818-588-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT-158791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: