Provider Demographics
NPI:1497287338
Name:JACKSON, WANDA MERCEDES
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:MERCEDES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:WANDA
Other - Middle Name:MERCEDES
Other - Last Name:TINEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1069 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-4996
Mailing Address - Country:US
Mailing Address - Phone:831-392-1500
Mailing Address - Fax:831-392-1501
Practice Address - Street 1:1069 BROADWAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4995
Practice Address - Country:US
Practice Address - Phone:831-392-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor