Provider Demographics
NPI:1073902854
Name:JACKSON, DYAMOND (MA)
Entity Type:Individual
Prefix:
First Name:DYAMOND
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N HILL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1949
Mailing Address - Country:US
Mailing Address - Phone:626-701-4249
Mailing Address - Fax:
Practice Address - Street 1:50 N HILL AVE STE 201
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1949
Practice Address - Country:US
Practice Address - Phone:626-701-4249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81475106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist