Provider Demographics
NPI:1699484550
Name:JACKSON FITZGERALD, TASHA
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:JACKSON FITZGERALD
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 1:336 BON AIR CTR # 271
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-3017
Mailing Address - Country:US
Mailing Address - Phone:415-505-2628
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST STE 341
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3022
Practice Address - Country:US
Practice Address - Phone:415-505-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT-273106H00000X
CA45578106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist