Healthcare Provider Details

I. General information

NPI: 1508288762
Provider Name (Legal Business Name): NICOLE S JACKSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001A EAST PKWY
SACRAMENTO CA
95823-2501
US

IV. Provider business mailing address

9146 E STOCKTON BLVD UNIT 1070
ELK GROVE CA
95624-9510
US

V. Phone/Fax

Practice location:
  • Phone: 916-873-0976
  • Fax:
Mailing address:
  • Phone: 916-873-0976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: