Provider Demographics
NPI:1568092088
Name:JACKSON, GREGORY CHRISTOPHER (PSYD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CHRISTOPHER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4141 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3109
Practice Address - Country:US
Practice Address - Phone:415-833-5067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31231103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist