Provider Demographics
NPI:1144611948
Name:JACKSON, YVONNE
Entity Type:Individual
Prefix:
First Name:YVONNE
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 1:2785 DEVONSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7222
Mailing Address - Country:US
Mailing Address - Phone:951-234-9555
Mailing Address - Fax:855-215-1562
Practice Address - Street 1:9567 ARROW RTE
Practice Address - Street 2:STE M
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4550
Practice Address - Country:US
Practice Address - Phone:909-774-1137
Practice Address - Fax:855-215-1562
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-15
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT93289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist