Provider Demographics
NPI:1003859992
Name:JACKSON, SARAH JANE (PHD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE D3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8661
Mailing Address - Country:US
Mailing Address - Phone:512-289-5486
Mailing Address - Fax:512-342-0421
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE D3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-289-5486
Practice Address - Fax:512-342-0421
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25807103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0073JBOtherBLUE CROSS BLUE SHIELD
TX0401218-06Medicaid
TX00194CMedicare ID - Type Unspecified