Provider Demographics
NPI:1114631991
Name:JACKSON-MCCOY, MICHELLE R (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:JACKSON-MCCOY
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 1:21200 OXNARD ST # 6132
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-5014
Mailing Address - Country:US
Mailing Address - Phone:310-403-6533
Mailing Address - Fax:
Practice Address - Street 1:21200 OXNARD ST STE 6132
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5014
Practice Address - Country:US
Practice Address - Phone:310-403-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling