MEDICARE: SUMMER JACKSON LCSW

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	1041C0700X	Clinical Social Worker	LCSW71611	CA

General Provider Information

NPI Number	:	1588301022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMMER JACKSON LCSW

Provider Business Mailing Address
First Line	:	1748 SHATTUCK AVE
Second Line	:	PMB 154
City	:	BERKELEY
State	:	CA
Zip	:	94709-1720
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 NEILSON ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94707-1813
Country	:	US
Telephone Number	:	510-406-4496
Fax Number	:

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

Provider Enumeration Date	:	05/17/2022
Last Update Date	:	05/17/2022

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