Provider Demographics
NPI:1194578476
Name:JACKSON, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4269
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91503-4269
Mailing Address - Country:US
Mailing Address - Phone:323-250-2780
Mailing Address - Fax:
Practice Address - Street 1:5740 YORK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-2617
Practice Address - Country:US
Practice Address - Phone:323-250-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1219041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical