Healthcare Provider Details

I. General information

NPI: 1407181712
Provider Name (Legal Business Name): CHARMAINE JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 E COLORADO BLVD STE 180&2ND
PASADENA CA
91101-6143
US

IV. Provider business mailing address

2640 LAKE AVE APT B
ALTADENA CA
91001-1943
US

V. Phone/Fax

Practice location:
  • Phone: 626-941-7645
  • Fax:
Mailing address:
  • Phone: 909-291-5766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW78456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: