Provider Demographics
NPI:1629205224
Name:JACKSON, JUDY (MFT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
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 1:110 N SANTA CRUZ AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5919
Mailing Address - Country:US
Mailing Address - Phone:408-380-3038
Mailing Address - Fax:408-380-3038
Practice Address - Street 1:110 N SANTA CRUZ AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5919
Practice Address - Country:US
Practice Address - Phone:408-380-3038
Practice Address - Fax:408-380-3038
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42499106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist