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General NPI Number Information
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NPI Number | 1619127537
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Entity Type | Individual
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Provider Name | ANNE ELIZABETH JACKSON PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/27/2008
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 1101 COLLEGE AVE STE 230
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City | SANTA ROSA
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State | CA
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Zip | 95404-3956
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Country | US
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Telephone | 650-444-3260
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Fax |
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Provider Business Mailing Address
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Address Line | 712 BANCROFT RD # 771
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City | WALNUT CREEK
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State | CA
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Zip | 94598-1531
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Country | US
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Telephone | 650-444-3260
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY17785
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY17785
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY17785
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License Number State | CA
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