Healthcare Provider Details

I. General information

NPI: 1275640195
Provider Name (Legal Business Name): VIOLETTE A JACKSON LCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD STE E4
POWAY CA
92064-2427
US

IV. Provider business mailing address

15525 POMERADO RD STE E4
POWAY CA
92064-2427
US

V. Phone/Fax

Practice location:
  • Phone: 858-674-5958
  • Fax: 858-451-1104
Mailing address:
  • Phone: 858-674-5958
  • Fax: 858-451-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS15995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: