Provider Demographics
NPI:1316518988
Name:JACKSON, BRANDI
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
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 1:17642 LOGANBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7465
Mailing Address - Country:US
Mailing Address - Phone:424-205-4729
Mailing Address - Fax:
Practice Address - Street 1:17642 LOGANBERRY RD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-7465
Practice Address - Country:US
Practice Address - Phone:424-205-4729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool