Provider Demographics
NPI:1548334634
Name:JACKSON CARLSON, NANCY JO
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:JO
Last Name:JACKSON CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:JO
Other - Last Name:JUVINALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:PO BOX 5536
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-0536
Mailing Address - Country:US
Mailing Address - Phone:925-426-4729
Mailing Address - Fax:
Practice Address - Street 1:2955 SHATTUCK AVE STE 2955
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:925-426-4729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT33820101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT33820OtherMARRIAGE & FAMILY THERAPY