Provider Demographics
NPI:1083972681
Name:JACKSON, JESSICA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 N CHERRY ST
Mailing Address - Street 2:APT. 47
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3770
Mailing Address - Country:US
Mailing Address - Phone:530-774-3646
Mailing Address - Fax:
Practice Address - Street 1:130 YELLOWSTONE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-5884
Practice Address - Country:US
Practice Address - Phone:530-879-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74276106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist