Provider Demographics
NPI:1487958757
Name:JACKSON, RACHELLE
Entity type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
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 5093
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-0509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:707-643-3863
Practice Address - Street 1:110 E D ST
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3254
Practice Address - Country:US
Practice Address - Phone:707-342-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-31
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA696661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical