Provider Demographics
NPI:1285837088
Name:JACKSON, GEORGIA (CATC)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE
Mailing Address - Street 2:WARD 93
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3518
Mailing Address - Country:US
Mailing Address - Phone:415-206-6142
Mailing Address - Fax:415-206-6875
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:WARD 93
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-6142
Practice Address - Fax:415-206-6875
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA051192IV101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
31836OtherSFGH INTERNAL USE ONLY
31836OtherCBHS INTERNAL USE ONLY-COMMERCIAL NUMBER