Provider Demographics
NPI:1013672153
Name:JACKSON, BRENDA (AMFT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010A HARBISON DR STE 437
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3900
Mailing Address - Country:US
Mailing Address - Phone:559-265-2332
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-2918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT128835101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health