Provider Demographics
NPI:1710096409
Name:JACKSON, DIANE (MFT)
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:300 HARDING BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2470
Mailing Address - Country:US
Mailing Address - Phone:916-772-3628
Mailing Address - Fax:
Practice Address - Street 1:300 HARDING BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2470
Practice Address - Country:US
Practice Address - Phone:916-772-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist