Healthcare Provider Details

I. General information

NPI: 1770950404
Provider Name (Legal Business Name): TAMEKA JACKSON B.S IN PSYCHOLOGY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 9TH ST
CRESCENT CITY CA
95531-3432
US

IV. Provider business mailing address

1310 BURTSCHELL ST
CRESCENT CITY CA
95531-2415
US

V. Phone/Fax

Practice location:
  • Phone: 916-696-4729
  • Fax:
Mailing address:
  • Phone: 916-696-4729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: