Provider Demographics
NPI:1497249841
Name:JACKSON, CAMERON S (PHD, JD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 FLORENCE DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-5031
Mailing Address - Country:US
Mailing Address - Phone:831-688-6002
Mailing Address - Fax:
Practice Address - Street 1:127 JEWELL ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1717
Practice Address - Country:US
Practice Address - Phone:831-688-6002
Practice Address - Fax:831-688-7717
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14762103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist