Provider Demographics
NPI:1760997217
Name:NAOMI JACKSON THE PROFESSION OF MARRIAGE AND FAMILY THERAPY
Entity Type:Organization
Organization Name:NAOMI JACKSON THE PROFESSION OF MARRIAGE AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:ELNORA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-674-4289
Mailing Address - Street 1:101 E REDLANDS BLVD STE 246
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4725
Mailing Address - Country:US
Mailing Address - Phone:909-674-4289
Mailing Address - Fax:909-363-8977
Practice Address - Street 1:101 E REDLANDS BLVD STE 246
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4725
Practice Address - Country:US
Practice Address - Phone:909-674-4289
Practice Address - Fax:909-363-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT80560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid