Provider Demographics
NPI:1972019669
Name:JACKSON, MAYA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:ELIZABETH
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 1:4000 W METROPOLITAN DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3504
Mailing Address - Country:US
Mailing Address - Phone:714-834-5015
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:714-834-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA958601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical