Provider Demographics
NPI:1245381318
Name:JACKSON, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
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 1:1001 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0730
Mailing Address - Country:US
Mailing Address - Phone:209-529-0373
Mailing Address - Fax:209-529-8519
Practice Address - Street 1:1001 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0730
Practice Address - Country:US
Practice Address - Phone:209-529-0373
Practice Address - Fax:209-529-8519
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist