Healthcare Provider Details

I. General information

NPI: 1063681732
Provider Name (Legal Business Name): SARA JACKSON M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

5400 LINDLEY AVE 323
ENCINO CA
91316-1907
US

V. Phone/Fax

Practice location:
  • Phone: 626-744-5230
  • Fax: 626-844-9137
Mailing address:
  • Phone: 805-732-4033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: