Provider Demographics
NPI:1871851626
Name:JACKSON, TEDDIE (PSYD)
Entity type:Individual
Prefix:MS
First Name:TEDDIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:TEDDIE
Other - Middle Name:CAITLIN
Other - Last Name:COX LANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:3805 DOVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2953
Mailing Address - Country:US
Mailing Address - Phone:916-396-5987
Mailing Address - Fax:
Practice Address - Street 1:1420 KETTNER BLVD STE 215
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2421
Practice Address - Country:US
Practice Address - Phone:916-388-9418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF69916106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist