Provider Demographics
NPI:1417608092
Name:JACKSON HENDERSON, NIA (LMFT)
Entity Type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:JACKSON HENDERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7381 LA TIJERA BLVD UNIT 451682
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-7076
Mailing Address - Country:US
Mailing Address - Phone:310-733-6275
Mailing Address - Fax:
Practice Address - Street 1:11850 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6629
Practice Address - Country:US
Practice Address - Phone:310-894-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 171R00000X
CA129531106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171R00000XOther Service ProvidersInterpreter