Provider Demographics
NPI:1619163599
Name:JACKSON, KARRIN LYNISE (LMP)
Entity type:Individual
Prefix:
First Name:KARRIN
Middle Name:LYNISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 CITRUS CIR STE 165
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2669
Mailing Address - Country:US
Mailing Address - Phone:925-553-3376
Mailing Address - Fax:
Practice Address - Street 1:3075 CITRUS CIR STE 165
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2669
Practice Address - Country:US
Practice Address - Phone:259-553-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
WAMA00017797225700000X
CA19070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program