Provider Demographics
NPI:1447502042
Name:JACKSON, RAQUEL G (MFT INTERN)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43845 10TH ST W STE 2B
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4800
Mailing Address - Country:US
Mailing Address - Phone:661-940-9094
Mailing Address - Fax:
Practice Address - Street 1:43845 10TH ST W STE 2B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4800
Practice Address - Country:US
Practice Address - Phone:661-940-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70614106H00000X
CA134474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist