Provider Demographics
NPI:1487721817
Name:JACKSON, ELISHA D (LCSW)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials: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 44417
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-0417
Mailing Address - Country:US
Mailing Address - Phone:562-218-4098
Mailing Address - Fax:562-218-4076
Practice Address - Street 1:240 EAST 20TH STREET
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-218-4098
Practice Address - Fax:562-218-4076
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16946101YM0800X
CALCS 263251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health