Provider Demographics
NPI:1205022597
Name:JACKSON, MERILEE D (MFT)
Entity Type:Individual
Prefix:MS
First Name:MERILEE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 TORRANCE BLVD
Mailing Address - Street 2:SUITE 460
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4810
Mailing Address - Country:US
Mailing Address - Phone:310-543-2430
Mailing Address - Fax:310-544-0585
Practice Address - Street 1:3655 TORRANCE BLVD
Practice Address - Street 2:SUITE 460
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4810
Practice Address - Country:US
Practice Address - Phone:310-543-2430
Practice Address - Fax:310-544-0585
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 18934106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist