Provider Demographics
NPI:1013946730
Name:JACKSON, GENEE DELYENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GENEE
Middle Name:DELYENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 THE ALAMEDA
Mailing Address - Street 2:SUITE 228
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1187
Mailing Address - Country:US
Mailing Address - Phone:415-860-6860
Mailing Address - Fax:855-860-6860
Practice Address - Street 1:921 THE ALAMEDA
Practice Address - Street 2:SUITE 228
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2311
Practice Address - Country:US
Practice Address - Phone:415-860-6860
Practice Address - Fax:855-860-6860
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical