Provider Demographics
NPI:1588053342
Name:JACKSON, TONI LOUISE
Entity type:Individual
Prefix:MS
First Name:TONI
Middle Name:LOUISE
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 1:1796 BAY RD
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1611
Mailing Address - Country:US
Mailing Address - Phone:650-462-6999
Mailing Address - Fax:650-462-1055
Practice Address - Street 1:1796 BAY RD
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1611
Practice Address - Country:US
Practice Address - Phone:650-462-6999
Practice Address - Fax:650-462-1055
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4912-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)