Provider Demographics
NPI:1407057003
Name:JACKSON, GAIL ALLSUP (PHD, MA, LMFT)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:ALLSUP
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E 118TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2518
Mailing Address - Country:US
Mailing Address - Phone:323-249-2950
Mailing Address - Fax:323-249-2970
Practice Address - Street 1:1770 E 118TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-2518
Practice Address - Country:US
Practice Address - Phone:323-249-2950
Practice Address - Fax:323-249-2970
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC11780106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist