Provider Demographics
NPI:1295181295
Name:JACKSON, SASHA
Entity Type:Individual
Prefix:
First Name:SASHA
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 1:480 RIDGE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-8776
Mailing Address - Country:US
Mailing Address - Phone:209-675-6442
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2403
Practice Address - Country:US
Practice Address - Phone:510-553-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool