Provider Demographics
NPI:1356304596
Name:JACKSON, JENNIFER BETH (LAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:BETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2824
Mailing Address - Country:US
Mailing Address - Phone:415-686-6077
Mailing Address - Fax:
Practice Address - Street 1:2005 BRIDGEWAY
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1736
Practice Address - Country:US
Practice Address - Phone:415-331-2024
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10107171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist