Provider Demographics
NPI:1669186490
Name:JACKSON, LARA JEANNE (LMFT)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:JEANNE
Last Name:JACKSON
Suffix:
Gender:
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S MELROSE DR
Mailing Address - Street 2:STE A #280
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7037
Mailing Address - Country:US
Mailing Address - Phone:760-230-3451
Mailing Address - Fax:
Practice Address - Street 1:1611 S MELROSE DR
Practice Address - Street 2:STE A #280
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7037
Practice Address - Country:US
Practice Address - Phone:760-230-3451
Practice Address - Fax:209-659-6382
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist