Provider Demographics
NPI:1396056446
Name:JACKSON-LANE, CARLETTA (JD)
Entity type:Individual
Prefix:
First Name:CARLETTA
Middle Name:
Last Name:JACKSON-LANE
Suffix:
Gender:F
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-3303
Mailing Address - Country:US
Mailing Address - Phone:415-330-6300
Mailing Address - Fax:415-330-6306
Practice Address - Street 1:150 EXECUTIVE PARK BLVD
Practice Address - Street 2:SUITE 3300
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-3303
Practice Address - Country:US
Practice Address - Phone:415-330-6300
Practice Address - Fax:415-330-6306
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor