Provider Demographics
NPI:1497971808
Name:JACKSON, ADRIANN M
Entity Type:Individual
Prefix:MS
First Name:ADRIANN
Middle Name:M
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 1:2716 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:CORRALITOS
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1027
Mailing Address - Country:US
Mailing Address - Phone:831-688-6293
Mailing Address - Fax:831-761-9987
Practice Address - Street 1:2716 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:CORRALITOS
Practice Address - State:CA
Practice Address - Zip Code:95076-1027
Practice Address - Country:US
Practice Address - Phone:831-688-6293
Practice Address - Fax:831-761-9987
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health