Provider Demographics
NPI:1760835300
Name:JACKSON, SUSAN H (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 KLAMATH RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0218
Mailing Address - Country:US
Mailing Address - Phone:951-217-6884
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE STE 125
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7701
Practice Address - Country:US
Practice Address - Phone:951-217-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 40347106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist