Provider Demographics
NPI:1255780078
Name:CARNES-JACKSON, TANEKA (LCSW)
Entity type:Individual
Prefix:
First Name:TANEKA
Middle Name:
Last Name:CARNES-JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 ARCH AIRPORT RD
Mailing Address - Street 2:#31072
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95213-3000
Mailing Address - Country:US
Mailing Address - Phone:951-377-0910
Mailing Address - Fax:
Practice Address - Street 1:3131 ARCH AIRPORT RD
Practice Address - Street 2:#31072
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95213-3000
Practice Address - Country:US
Practice Address - Phone:951-377-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA657151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical