Provider Demographics
NPI:1417257312
Name:JACKSON, DIANE WESSON (MFC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:WESSON
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 1:1531 PURDUE AVE
Mailing Address - Street 2:SUITE NUMBER 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3104
Mailing Address - Country:US
Mailing Address - Phone:310-478-6263
Mailing Address - Fax:310-456-8456
Practice Address - Street 1:1531 PURDUE AVE
Practice Address - Street 2:SUITE NUMBER 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3104
Practice Address - Country:US
Practice Address - Phone:310-478-6263
Practice Address - Fax:310-456-8456
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC13334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFEID 95-4177659OtherFEDERAL ID FOR TAXES