Provider Demographics
NPI:1295113900
Name:HACKMAN, SALLY JO (MFT)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:JO
Last Name:HACKMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-3002
Mailing Address - Country:US
Mailing Address - Phone:310-451-3373
Mailing Address - Fax:310-393-2295
Practice Address - Street 1:522 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-3002
Practice Address - Country:US
Practice Address - Phone:310-451-3373
Practice Address - Fax:310-393-2295
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health