Provider Demographics
NPI:1780867101
Name:JACKSON, SARAH MONIQUE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MONIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MASON CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1203
Mailing Address - Country:US
Mailing Address - Phone:925-521-1270
Mailing Address - Fax:
Practice Address - Street 1:205 MASON CIR
Practice Address - Street 2:SUITE A
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1203
Practice Address - Country:US
Practice Address - Phone:925-521-1270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF52161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist