Provider Demographics
NPI:1396926499
Name:JACKSON, SHIRLEY (SOCIAL SERVICE WORK)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SOCIAL SERVICE WORK
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 1405
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92502-1405
Mailing Address - Country:US
Mailing Address - Phone:951-341-6440
Mailing Address - Fax:
Practice Address - Street 1:3625 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3815
Practice Address - Country:US
Practice Address - Phone:951-955-1582
Practice Address - Fax:951-955-1610
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health