Provider Demographics
NPI:1255793501
Name:JACKSON, BRANDI NICOLE (MSW)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 W SUNSET BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6309
Mailing Address - Country:US
Mailing Address - Phone:510-674-5555
Mailing Address - Fax:
Practice Address - Street 1:5504 MONTEREY HWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1529
Practice Address - Country:US
Practice Address - Phone:510-674-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89088101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health