Provider Demographics
NPI:1700983509
Name:JACKSON, TERI LEA
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:LEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6219 STONEHEDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-9519
Mailing Address - Country:US
Mailing Address - Phone:530-713-8266
Mailing Address - Fax:
Practice Address - Street 1:555 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4808
Practice Address - Country:US
Practice Address - Phone:530-251-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68899106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68899OtherBOARD OF BEHAVIORAL SCIENCES