Provider Demographics
NPI:1245600444
Name:JACKSON, SYLVIA (MA)
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 TREAT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5234
Mailing Address - Country:US
Mailing Address - Phone:415-641-8000
Mailing Address - Fax:
Practice Address - Street 1:1550 TREAT AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-5234
Practice Address - Country:US
Practice Address - Phone:415-641-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA126556013Medicaid