Provider Demographics
NPI:1407181712
Name:JACKSON, CHARMAINE (LCSW)
Entity type:Individual
Prefix:
First Name:CHARMAINE
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 1:2640 LAKE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-1943
Mailing Address - Country:US
Mailing Address - Phone:909-291-5766
Mailing Address - Fax:
Practice Address - Street 1:680 E COLORADO BLVD STE 180&2ND
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-6143
Practice Address - Country:US
Practice Address - Phone:626-941-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW784561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical