Provider Demographics
NPI:1588850473
Name:JACKSON, MARINA MARCIA (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:MARCIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1144
Mailing Address - Country:US
Mailing Address - Phone:510-418-5507
Mailing Address - Fax:
Practice Address - Street 1:516 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5429
Practice Address - Country:US
Practice Address - Phone:510-418-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38559106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01674804OtherMEDICAL