Healthcare Provider Details

I. General information

NPI: 1083021968
Provider Name (Legal Business Name): MICHELLE LORRAINE JACKSON ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2014
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 GUERNEVILLE RD STE 218
SANTA ROSA CA
95403-7255
US

IV. Provider business mailing address

1421 GUERNEVILLE RD
SANTA ROSA CA
95403-7220
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-7700
  • Fax: 707-576-7744
Mailing address:
  • Phone: 707-576-7700
  • Fax: 707-576-7744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW59973
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW59973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: