Healthcare Provider Details

I. General information

NPI: 1164576252
Provider Name (Legal Business Name): CHERYL ANN JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MCDONNELL AVE
COMMERCE CA
90040-5623
US

IV. Provider business mailing address

328 ANNA MARIA DR
ALTADENA CA
91001-4006
US

V. Phone/Fax

Practice location:
  • Phone: 323-981-4301
  • Fax:
Mailing address:
  • Phone: 626-798-1346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS17478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: