MEDICARE: DR. SALLY JO HACKMAN MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MFC29541	CA

General Provider Information

NPI Number	:	1295113900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY JO HACKMAN MFT

Provider Business Mailing Address
First Line	:	522 16TH ST
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-3002
Country	:	US
Telephone Number	:	310-451-3373
Fax Number	:	310-393-2295

Provider Business Practice Location Address
First Line	:	522 16TH ST
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-3002
Country	:	US
Telephone Number	:	310-451-3373
Fax Number	:	310-393-2295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2015
Last Update Date	:	05/13/2015

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