Healthcare Provider Details

I. General information

NPI: 1851873962
Provider Name (Legal Business Name): AMANI JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

IV. Provider business mailing address

2594 INDUSTRY WAY
LYNWOOD CA
90262-4015
US

V. Phone/Fax

Practice location:
  • Phone: 323-593-5300
  • Fax:
Mailing address:
  • Phone: 310-667-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number94251
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138873
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number94251
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: