Healthcare Provider Details

I. General information

NPI: 1114631991
Provider Name (Legal Business Name): MICHELLE R JACKSON-MCCOY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 07/08/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21200 OXNARD ST STE 6132
WOODLAND HILLS CA
91367-5014
US

IV. Provider business mailing address

21200 OXNARD ST # 6132
WOODLAND HILLS CA
91367-5014
US

V. Phone/Fax

Practice location:
  • Phone: 310-403-6533
  • Fax:
Mailing address:
  • Phone: 310-403-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: