Provider Demographics
NPI:1437023108
Name:JACKSON, SAMIRAH NASIHA
Entity type:Individual
Prefix:
First Name:SAMIRAH
Middle Name:NASIHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DURANT AVE # 644A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1610
Mailing Address - Country:US
Mailing Address - Phone:470-529-6378
Mailing Address - Fax:
Practice Address - Street 1:2401 DURANT AVE # 644A
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1610
Practice Address - Country:US
Practice Address - Phone:470-529-6378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst