Provider Demographics
NPI:1790277648
Name:JACKSON, JACARI DA VON
Entity Type:Individual
Prefix:MR
First Name:JACARI
Middle Name:DA VON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14003 EADALL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2143
Mailing Address - Country:US
Mailing Address - Phone:310-409-3118
Mailing Address - Fax:
Practice Address - Street 1:14003 EADALL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2143
Practice Address - Country:US
Practice Address - Phone:424-250-8272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAASW89841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program