Provider Demographics
NPI:1740478155
Name:JACKSON, MICHAEL L (MFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 S MARENGO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3113
Mailing Address - Country:US
Mailing Address - Phone:626-585-9146
Mailing Address - Fax:626-792-4308
Practice Address - Street 1:448 S MARENGO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3113
Practice Address - Country:US
Practice Address - Phone:626-585-9146
Practice Address - Fax:626-792-4308
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 16923101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health