Provider Demographics
NPI:1790908788
Name:JACKA, KAREN ANN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:JACKA
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 1:21 S CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1907
Mailing Address - Country:US
Mailing Address - Phone:209-483-6474
Mailing Address - Fax:209-367-4696
Practice Address - Street 1:404 W PINE ST STE 1
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-483-6474
Practice Address - Fax:209-367-4696
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS164701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3810106OtherPROVIDER # AETNA
CA48809OtherPRIVIDER NUMBER MHN
CAA881670OtherVALUE OPITIONS VENDOR NUM
CA62-79934OtherPROV. NO.UNITED HEALTH CA