Basic Information
| Provider Information | |||||||||
| NPI: | 1386810208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SELENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BREININGINSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 390 N FORBES ST | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954534724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079945486 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RI-J0803091809 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.