Healthcare Provider Details

I. General information

NPI: 1619349933
Provider Name (Legal Business Name): PHOENIX JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

IV. Provider business mailing address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

V. Phone/Fax

Practice location:
  • Phone: 415-610-1768
  • Fax:
Mailing address:
  • Phone: 415-610-1768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number91873
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91873
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number91873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: