Provider Demographics
NPI:1417320995
Name:JACKSON, PAMELA ELAINE (CAS)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 BANCROFT AVE STE 176
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2411
Mailing Address - Country:US
Mailing Address - Phone:510-568-2432
Mailing Address - Fax:510-568-3912
Practice Address - Street 1:7200 BANCROFT AVE STE 176
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2411
Practice Address - Country:US
Practice Address - Phone:510-568-2432
Practice Address - Fax:510-568-3912
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC031390315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)