Healthcare Provider Details

I. General information

NPI: 1063084606
Provider Name (Legal Business Name): SAVANNAH C JACKSON AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4858 MERCURY ST STE 100
SAN DIEGO CA
92111-2128
US

IV. Provider business mailing address

630 1ST AVE
SAN DIEGO CA
92101-6976
US

V. Phone/Fax

Practice location:
  • Phone: 833-427-7873
  • Fax:
Mailing address:
  • Phone: 619-784-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT164126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: