Provider Demographics
NPI:1851423206
Name:JACKSON-THOMPSON, GEORGIA ANN (MA)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:ANN
Last Name:JACKSON-THOMPSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9626 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-4311
Mailing Address - Country:US
Mailing Address - Phone:323-779-0729
Mailing Address - Fax:323-779-0739
Practice Address - Street 1:16090 JACKSON DRVIE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-429-1216
Practice Address - Fax:909-429-1216
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40585101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF 40585Medicare UPIN