Provider Demographics
NPI:1023801933
Name:JACKSON, MIA ALEXANDRIA (AMFT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:ALEXANDRIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10190 RAMONA DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1806
Mailing Address - Country:US
Mailing Address - Phone:619-750-9134
Mailing Address - Fax:
Practice Address - Street 1:446 ALTA RD # 6100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92158-0001
Practice Address - Country:US
Practice Address - Phone:619-671-6590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist