Provider Demographics
NPI:1619300886
Name:JACKSON, MICHELLE BETH (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 SANTA MONICA BLVD STE 379
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1542
Mailing Address - Country:US
Mailing Address - Phone:818-646-6281
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD STE 379
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1542
Practice Address - Country:US
Practice Address - Phone:818-646-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29440103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical