Provider Demographics
NPI:1699969188
Name:JACKSON-MASSARO, KIMBERLY ERIN (MSW/LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ERIN
Last Name:JACKSON-MASSARO
Suffix:
Gender:F
Credentials:MSW/LCSW
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ERIN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3625 1ST AVE APT 38
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4033
Mailing Address - Country:US
Mailing Address - Phone:619-578-9255
Mailing Address - Fax:
Practice Address - Street 1:3031 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-6904
Practice Address - Country:US
Practice Address - Phone:619-578-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health