Provider Demographics
NPI:1902970726
Name:JACKSON, JANE G (PHD PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD PSYCHOLOGIST
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 #1993
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92314
Mailing Address - Country:US
Mailing Address - Phone:909-584-9363
Mailing Address - Fax:760-843-0507
Practice Address - Street 1:16519 VICTOR ST SUITE #406
Practice Address - Street 2:BEHAVIORAL HEALTH CONSULTANTS
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:760-843-0506
Practice Address - Fax:760-843-0507
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL114601Medicare ID - Type Unspecified