Provider Demographics
NPI:1871048520
Name:JACKSON, SUSAN MARIE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
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 1:1125 W 6TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1896
Mailing Address - Country:US
Mailing Address - Phone:213-202-3970
Mailing Address - Fax:213-241-0925
Practice Address - Street 1:1125 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1833
Practice Address - Country:US
Practice Address - Phone:213-241-0979
Practice Address - Fax:213-241-0925
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator