Provider Demographics
NPI:1154687028
Name:WINSTON, JACKIE
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:
Last Name:WINSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELLA
Other - Middle Name:JACQUELINE
Other - Last Name:WINSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8817 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2421
Mailing Address - Country:US
Mailing Address - Phone:323-750-8558
Mailing Address - Fax:
Practice Address - Street 1:614 W MANCHESTER BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1656
Practice Address - Country:US
Practice Address - Phone:310-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)