Provider Demographics
NPI:1972631745
Name:JACKSON, MICHELLE CHRISTINE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CHRISTINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW
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 10062
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838-6062
Mailing Address - Country:US
Mailing Address - Phone:714-616-8406
Mailing Address - Fax:
Practice Address - Street 1:18200 YORBA LINDA BLVD
Practice Address - Street 2:STE. 405
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4056
Practice Address - Country:US
Practice Address - Phone:714-616-8406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19726317451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical