Provider Demographics
NPI:1851826168
Name:JACKSON-WILSON, SHERMAN BILLY
Entity Type:Individual
Prefix:
First Name:SHERMAN
Middle Name:BILLY
Last Name:JACKSON-WILSON
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 1:2116 ARLINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-1353
Mailing Address - Country:US
Mailing Address - Phone:323-737-3900
Mailing Address - Fax:
Practice Address - Street 1:2116 ARLINGTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1353
Practice Address - Country:US
Practice Address - Phone:213-745-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107548106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program