Provider Demographics
NPI:1942485768
Name:JACKY, SUSAN JOAN (ACSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOAN
Last Name:JACKY
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUIR RD
Mailing Address - Street 2:11C-3
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4668
Mailing Address - Country:US
Mailing Address - Phone:925-372-2156
Mailing Address - Fax:925-372-2017
Practice Address - Street 1:150 MUIR RD
Practice Address - Street 2:11C-3
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:925-372-2156
Practice Address - Fax:925-372-2017
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW188821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical