Provider Demographics
NPI:1891137444
Name:JACKSON, COLLEEN C
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:C
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 1:1430 NEOTOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7575
Mailing Address - Country:US
Mailing Address - Phone:707-565-7479
Mailing Address - Fax:
Practice Address - Street 1:2227 CAPRICORN WAY STE 210
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5486
Practice Address - Country:US
Practice Address - Phone:707-565-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65164106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist