Provider Demographics
NPI:1275640195
Name:JACKSON, VIOLETTE A (LCS)
Entity Type:Individual
Prefix:
First Name:VIOLETTE
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD STE E4
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2427
Mailing Address - Country:US
Mailing Address - Phone:858-674-5958
Mailing Address - Fax:858-451-1104
Practice Address - Street 1:15525 POMERADO RD STE E4
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2427
Practice Address - Country:US
Practice Address - Phone:858-674-5958
Practice Address - Fax:858-451-1104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS159951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW15995Medicare UPIN