Provider Demographics
NPI:1417076241
Name:JACKSON, COURTNEY LARESIC
Entity Type:Individual
Prefix:MR
First Name:COURTNEY
Middle Name:LARESIC
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3372 RIVERMONT ST
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-5443
Mailing Address - Country:US
Mailing Address - Phone:916-371-9338
Mailing Address - Fax:
Practice Address - Street 1:608 10TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-0712
Practice Address - Country:US
Practice Address - Phone:916-441-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor