Provider Demographics
NPI:1306670195
Name:JACKSON, SEANA ALYSSA
Entity type:Individual
Prefix:
First Name:SEANA
Middle Name:ALYSSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SEANA
Other - Middle Name:ALYSSA
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41760 IVY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9416
Mailing Address - Country:US
Mailing Address - Phone:951-595-4673
Mailing Address - Fax:
Practice Address - Street 1:41760 IVY ST STE 102
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9416
Practice Address - Country:US
Practice Address - Phone:951-595-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician