Provider Demographics
NPI:1326492026
Name:JACKSON, SHELLI (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 WOODLAND PKWY STE 101-48
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2220
Mailing Address - Country:US
Mailing Address - Phone:760-593-4353
Mailing Address - Fax:
Practice Address - Street 1:979 WOODLAND PKWY STE 101-48
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2220
Practice Address - Country:US
Practice Address - Phone:760-505-6665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32087103TC0700X, 103TB0200X, 103TH0004X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy