Provider Demographics
NPI:1407344518
Name:RECORD-JACKSON, CHRISTIAN NICOLE (AMFT105956)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:NICOLE
Last Name:RECORD-JACKSON
Suffix:
Gender:F
Credentials:AMFT105956
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38607 BIRCH CIR
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:CA
Mailing Address - Zip Code:93644-9632
Mailing Address - Country:US
Mailing Address - Phone:559-683-2084
Mailing Address - Fax:209-317-4020
Practice Address - Street 1:5320 HIGHWAY 49 N STE 4A
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9588
Practice Address - Country:US
Practice Address - Phone:559-683-2084
Practice Address - Fax:209-317-4020
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105956101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional