Provider Demographics
NPI:1407170665
Name:JACKSON, SANDRA MARIE (MFC)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BX 2932
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92516
Mailing Address - Country:US
Mailing Address - Phone:951-231-1579
Mailing Address - Fax:951-789-1511
Practice Address - Street 1:6809 INDIANA AVE STE B8
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-231-1579
Practice Address - Fax:951-789-1511
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18385106H00000X
CAMFC18385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist