Provider Demographics
NPI:1962665067
Name:JACKSON, BROOKE P (PSYD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1449
Mailing Address - Country:US
Mailing Address - Phone:415-609-2361
Mailing Address - Fax:
Practice Address - Street 1:1044 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1449
Practice Address - Country:US
Practice Address - Phone:415-609-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27339103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical