Provider Demographics
NPI:1366637993
Name:JACKSON, ANITA IRENE
Entity Type:Individual
Prefix:MISS
First Name:ANITA
Middle Name:IRENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:IRENE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STUDENT
Mailing Address - Street 1:2311 LOVERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5117
Mailing Address - Country:US
Mailing Address - Phone:925-431-2647
Mailing Address - Fax:
Practice Address - Street 1:2311 LOVERIDGE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5117
Practice Address - Country:US
Practice Address - Phone:925-431-2647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA945871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical